VOLUNTARY SEPARATION INCENTIVE PAYMENTS
Individuals who have received a Voluntary Separation Incentive Payment, otherwise
known as a Buyout, must repay that incentive if they are reemployed by the Federal
government within five years. Please check the appropriate box and sign this form to
certify that you have not received a buyout.
I have not received a voluntary separation incentive payment within the last five years.
I have received a voluntary separation incentive payment within the last five years.
DS-7664
5-2015
U.S. Department of State
Signature Date (mm-dd-yyyy)
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