Form DS-7655 IRAQI CITIZENS AND NATIONALS EMPLOYED BY FEDERAL CONTRAC

U.S Department of State

IRAQI CITIZENS AND NATIONALS EMPLOYED BY FEDERAL
CONTRACTORS, GRANTEES & COOPERATIVE
AGREEMENT PARTNERS

OMB APPROVAL NO. 1405-xxxx
EXPIRATION DATE:
ESTIMATED BURDEN: 30 MIN

The following questions must be answered for each Iraqi citizen and national formerly or presently employed under a Department of State contract,
grant or cooperative agreement. Please ATTACH a passport-size photo and TYPE responses in the space provided below each item.

Employee

.tif or .bmp Formats Only

1. Family/Tribal Name
(Please list all variations)

Attach Passport-Size Photo Here of
Full Frontal View of the Face

2. First and Middle Names
(Please list all variations)

3. Date of Birth (dd mmm yyyy)

4. Gender

Female

Male

.tif or .bmp Formats Only

Family
5. Father's Full Name (Last, First, Middle)
(Please list all variations)

5. Father's Full Name (Last, First, Middle)
6. Mother's Full Name (Last, First, Middle)
(Please list all variations)

7. Grandfather's Full Name (Last, First, Middle)
(Please list all variations)

Employment
8. Name of Employer

9. Employer Human Resources Point of Contact
(Please list name, email, and phone number)

10. Employee Supervisor
(Please list name, email, and phone number)

11. Dates of Employment (dd mmm yyyy)

Location of Employment

From
To
From
To
From
To
12. Is the person in good standing?

Yes
DS-7655
04-2009

No

Employee Badge Number

13. Comments

Privacy Act & Paperwork Reduction Act Statements
AUTHORITY: The information solicited on this form is requested pursuant to Section 1248 of the Refugee Crisis in Iraq Act of 2008 included in the National Defense
Authorization Act of 2008 (P.L. 110-181).
PURPOSE: The primary purpose for soliciting the information is to verify the employment of Iraqi citizens and nationals by Federal contractors, grantees and cooperative
agreement partners.
ROUTINE USES: The information solicited on this form will be used by the Departments of State and Homeland Security to adjudicate refugee, asylum, special immigrant
visa, and other immigration claims and applications. Failure to provide the information requested on this form may result in delay or denial of application or claim.
PAPERWORK REDUCTION: Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time required for searching
existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do not have to
supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden estimate and/or
recommendations for reducing it, please send them to: A/ISS/DIR, Room 2400 SA-22, U.S. Department of State, Washington, DC 20522-2202.

DS-7655

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