Dss Form 273 – Fill Out and Use This PDF

PRIVACY ACT ADVISEMENT:

AUTHORITY: Executive Order 10450, 9397; and Public Law 99-474, the Computer Fraud and Abuse Act.

PRINCIPAL PURPOSE: To record names, signatures, and Social Security Numbers for the purpose of validating the trustworthiness

of individuals requesting access to Department of Defense (DoD) systems and information. NOTE: Records may be maintained in both electronic and/or paper form.

ROUTINE USES: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or information contained therein may specifically be disclosed outside DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: To a Federal, State, or local law enforcement agency when your agency becomes aware of a violation or possible violation of civil or criminal law; to the Department of Justice for the purposes of representing the DoD in pending or potential litigation to which the record is pertinent; to the Merit Systems Protection Board for the purpose of litigation or investigation of alleged or possible prohibited personnel practices; to a Federal agency when conducting an investigation or inquiry for security or audit reasons; or the General Services Administration in connection with its responsibilities for records management.

DISCLOSURE: Disclosure of this information (to include social security number) is voluntary; however, failure to provide the requested information will impede, delay or prevent further processing of this request.

3.USER INFORMATION (Must fill in completely; please type)

Business/Duty Station Address (street, city, state, zip code):

User’s Last Name, First Initial: ________________________________________________

6.JAMS USER ROLES (DoD/Non-Industry Only)

Special Case User Can Handle:

Investigation Request Permissions:

7. NOMINATING OFFICIAL’S CERTIFICATION (Note 1)

I certify that the above named individual meets the requirements for access and account management privileges. Furthermore, I certify that the named user requires account/access as indicated above in order to perform assigned duties.

8. USER’S CERTIFICATION

I hereby certify that I understand that by signing this System Access Request, I am solely responsible for the use and protection of the user ID and password that I will be provided. I also understand that I am not authorized to share my user ID and password with any other individuals. I will utilize all tools and applications in accordance with the Account Management Policy and Security Policy, as well as all applicable U.S. laws and DoD regulations.

User’s Printed NameUser’s Signature and Date

9. VALIDATING OFFICIAL’S VERIFICATION (Note 2)

I have verified with the appropriate security official/manager that minimum investigative requirements for the above user have been met.

10.ADDITIONAL SAR DIRECTIVES

•The SAR must be signed by the Nominating Official and the User or it will not be processed.

•Refer to page 3 of this form and JPAS, ISFD, DCII and SWFT Frequently Asked Questions (FAQs) at https://www.dss.mil or https://www.dmdc.osd.mil/psawebdocs, for additional SAR submission procedures pertaining to the respective systems (for example, please be advised that the DSS DoD Security Services Center does not process JCAVS access requests for military personnel; these requests should be submitted to the appropriate military agency approving authority).

•SARs requiring DSS processing/approval should be submitted to the DoD Security Services Center via fax number 703.493.8965, e-mail address account.request@dsshelp.org, or mailing address DoD Security Services Center, 10430 Furnace Road, Suite 101, Lorton, VA, 22079. Please allow at least three (3) business days for the SAR to be processed by the DoD Security Services Center. Notification of access will be sent to the User’s e-mail address. To ensure receipt of the access notification e-mail, add account.request@dsshelp.org to your e-mail contacts list.

•The completed SAR must be maintained by the account manager for a minimum of six (6) months after the account is deleted.

Notes:

1.Nominating Official may be the Facility Security Officer, KMP, Security Manager, Information Systems Security Officer, Agency Administrator, etc. In most cases, the Nominating Official MUST be other than the User.

2.Validating Official is either a representative of the DoD Security Services Center, or if the SAR is staying within the organization, the appropriate security official. For non-DoD government agency requests, non-DoD government agency security officials must complete this section.