Exhibit C2 DD2875 SAAR (fillable)

SYSTEM AUTHORIZATION ACCESS REQUEST (SAAR)

PRIVACY ACT STATEMENT

AUTHORITY: Executive Order 10450, 9397; and Public Law 99-474, the Computer Fraud and Abuse Act PRINCIPAL PURPOSE: To record names, signatures, and other identifiers 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: None.
DISCLOSURE: Disclosure of this information is voluntary; however, failure to provide the requested information may impede, delay or prevent further processing of this request.

CAC ID #:

TYPE OF REQUEST

DATE (YYYYMMDD)

□ INITIAL □ MODIFICATION □ DEACTIVATE □

SYSTEM NAME (Platform or Applications)

LOCATION (Physical Location of System)

DHHQ/NSS

PART I (To be completed by Requester)

1. NAME (Last, First, Middle Initial)

2. ORGANIZATION

3. OFFICE SYMBOL/DEPARTMENT

4. PHONE (DSN or Commercial)

5. OFFICIAL E-MAIL ADDRESS

6. JOB TITLE AND GRADE/RANK

7. OFFICIAL MAILING ADDRESS

8. CITIZENSHIP

□ US

9. DESIGNATION OF PERSON

□ FN

□ OTHER

□ MILITARY □ CIVILIAN

□ CONTRACTOR

10. IA TRAINING AND AWARENESS CERTIFICATION REQUIREMENTS (Complete as required for user or functional level access.)

DATE (YYYYMMDD)

□ I have completed Annual Information Awareness Training.

11. USER SIGNATURE

12. DATE (YYYYMMDD)

PART II ENDORSEMENT OF ACCESS BY INFORMATION OWNER, USER SUPERVISOR OR GOVERNMENT SPONSOR (If individual is a contractor provide company name, contract number, and date of contract expiration in Block 16.)

13. JUSTIFICATION FOR ACCESS

14. TYPE OF ACCESS REQUESTED

□ AUTHORIZED □ PRIVILEGED

Unclassified

15. USER REQUIRES ACCESS TO:

□
□ OTHER (Please Specify)

16. VERIFICATION OF NEED TO KNOW

□

I certify that this user requires access as requested

17. SUPERVISOR'S NAME (Print Name)

20. SUPERVISOR'S ORGANIZATION/DEPARTMENT

21. SIGNATURE OF GOVERNMENT POC

22. SIGNATURE OF ISSO/ISSM OR DESIGNEE

DD FORM 2875, May 2022

□

Classified

16a. ACCESS EXPIRATION DATE (Contractors must specify Company Name, Contract Number, Expiration Date. Use Block 27 if needed.)

18. SUPERVISOR SIGNATURE

19. DATE (YYYYMMDD)

20a. SUPERVISOR'S EMAIL ADDRESS

20b. PHONE NUMBER

21a. PHONE NUMBER

23. ORGANIZATION/DEPARTMENT

24. PHONE NUMBER

21b. DATE (YYYYMMDD)

25. DATE (YYYYMMDD)

26. NAME (Last, First, Middle Initial)

27. OPTIONAL INFORMATION

**Share Drive access**
Please provide at least one of the following:
1) Path of drive(s):
OR
2) Name/Email address of existing user to mirror requester access to: