Form DS 7655 DS 7655 Iraqi Citizens and Nationals Employed by Federal Contrac

U.S Department of State

IRAQI CITIZENS AND NATIONALS EMPLOYED BY U.S. FEDERAL
CONTRACTORS, GRANTEES AND COOPERATIVE
AGREEMENT PARTNERS

OMB CONTROL NO. 1405-0184
EXPIRATION DATE: XX/XX/20XX
ESTIMATED BURDEN: 30 MIN

A completed DS-7655 is needed for each Iraqi citizen and national employed under a Department of State prime contract, prime grant or prime
cooperative agreement including for Iraqis employed under related contracts, subcontracts or subgrants issued for work performed in IRAQ. Please
attach a digital passport-size photo of the employee and type responses in the space provided below.

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

Please attach a digital passport-size
photo here with a full frontal view of
the employee's face.

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

3. Date of Birth (dd mmm yyyy ~ eg: 01 JAN 1970)

Digital photos should be in .tif or
.bmp file formats only.

4. Gender

Male

Female

Family
5. Father's Full Name (Family/Tribal Name, First and Middle Names)
(Please list all variations )

5. Father's Full Name (Last, First, Middle)
6. Mother's Full Name (Family/Tribal Name, First and Middle Names)
(Please list all variations )

7. Grandfather's Full Name (Family/Tribal Name, First and Middle Names)
(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 (Most recent)
(Please list name, email, and phone number)

11. Dates of Employment (dd mmm yyyy ~ eg: 01 JAN 1970)

Location of Employment

Employee Badge Number

From
To
From
To
From
To
12. Was this employee terminated for cause? If YES, please provide reason for termination in Section 13 below.

Yes
DS-7655
07-2017

No
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13. Comments

Confidentiality Statement and Paperwork Reduction Act Statements
CONFIDENTIALITY STATEMENT:
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). 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. 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: PRM/A, 2025 E Street, NW, SA-9, 8th floor, Washington, DC 20522-0908.

DS-7655

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