drf1 derivative residence card application for a derivative

DRF1Derivative Residence Card

Application for a derivative residence card as a person with a derivative right of

residence under EU law

Any further reference on this form to ‘EEA nationals’ includes Swiss nationals.

Use this application form if you wish to apply for a derivative residence card as:

• theprimarycarerofaBritishcitizenchildordependentadult(‘Zambrano’),

• theprimarycarerofaself-sufficientEEAnationalchild(‘Chen’)

• thechildofanEEAnationalformerworkerwherethechildisineducationintheUK(‘Ibrahim/Teixeira’)

• theprimarycarerofachildofanEEAnationalformerworkerwherethechildisineducationintheUK(‘Ibrahim/Teixeira’),or

• thedependentchildagedunder18ofaprimarycarerinoneofthecategoriesabove.

You will only be considered for a derivative residence card as a person with a derivative right of residence under EU law. You will not be considered for anything else. You must use a different form if you want to stay for another reason.

Version03/2017

Thisformistobeusedforapplicationsmadeonorafter22March2017

DerivativeResidenceCard(DRF1)-Version03/2017 Page2of74

The fee

Thereisafeeof£65foreachpersonapplyingforaderivativeresidencecard.Ifyoudonotpaythefee,yourapplicationwillbeinvalidandreturnedtoyouwithoutconsideration.Seethepaymentguidancenotes,enclosedwiththisapplicationform,forfurtherinformation.

Each person claiming a derivative right of residence must complete their own application form andpaythespecifiedfee.

Biometric information for non-EEA nationals

Ifyouareanon-EEAnationalapplyingforaderivativeresidencecard,youmustgiveyourbiometricinformation(fingerprintsandadigitalphotograph)beforeyourapplicationwillbeconsidered.Ifyoudonot,wemayrejectyourapplication.

Seepages7-12ofthisformforfurtherinformation.

Completing the application form

Completeallrelevantsectionsoftheformasdirected.Useablackpenandwritenames,addressesandsimilardetailsincapitalletters.Insectionswhereyouareaskedtogiveyourpersonaldetailsandaddress,leaveaspacebetweeneachnameandeachpartoftheaddress.

Youmustalsosendtherelevantevidenceasspecifiedinsection9ofthisform.

Onlycompletethesectionsoftheformthatarerelevanttoyou.Ifasectiondoesnotapplytoyou,leaveitblank.

Ifthereisinsufficientspaceinanysectionoftheapplicationform,pleasecontinueonaseparatesheet.

Tosavepaper,postageandstoragecosts,werecommendthatyouonlyprintandsendusthe:

•frontpageoftheform,and

•sectionsoftheformthatyouhaveactuallycompleted(includingthepaymentsectionand,ifrequired,thebiometricsection).

Where to send your completed application

ApplicationsonthisformcannotbemadeatourPremiumServiceCentres.

Youmustsendthecompletedapplicationform,supportingdocuments,andpaymentof£65totheaddressbelow:

HomeOffice–Derivativerightsapplications

POBox639

Durham

DH19LB

Sending it to any other address may delay your application.


Payment Guidance

The FeeThereisafeeof£65forthisapplication.

Pleasenotethatyourapplicationwillberejectedasinvalidifyoudonotpaythespecifiedfee.

How you can payYoucanpaybyanyofthefollowingmethods:

•Cheque/BankersDraft

•Postal Order

•Creditcard-Mastercard,Visa(includingElectron)orAmericanExpress(Amex)

•Debitcard-Delta,Maestro*(includingSolo)

*Maestro-WecanacceptonlyMaestrocardsissuedintheUK.

Pleasenotethatwhenmakinglargeormultiplepaymentsusingyourcreditcard,theanti-fraudmeasuresthatbanksoperatesometimesstopthefullpaymentbeingtaken.Thiscanhappenforanumberofreasons.Topreventthisyoumaywishtoinformyourbankofyourintentiontomakelargeormultiplepaymentsinadvancesothatyourbankallowsthefullpaymenttobetakenwhenyousubmityourapplication.Pleasebeawarethatnotallbanksofferthisservice.

Cheques and postal ordersYoumustmakethechequeorpostalorderpayableto‘HomeOffice’andcrossthechequeorpostalorderA/CPayeeonly.Pleasewritethefullnameanddateofbirthoftheapplicantonthebackofthechequeand/oreachpostalorderandkeepthepostalorderreceipt(s).Pleasemakesurethatthedateandtheamount(wordsandfigures)arecorrectandthatthechequeissignedproperly.Attachyourchequeorpostalorder(s)tothefrontoftheapplicationform.

Completing the payment details pageToensurethatyourpaymentisprocessedwithoutanydelay,pleasefollowthisguidancewhencompleting the Payment Details section.

1-2 Theaddressat1shouldbethecontactaddressintheUKforanycorrespondence.Ifitisnotyourhomeaddress(egasolicitororotherauthorisedimmigrationadvisermaybesubmittingtheapplication),givethecontactnameat2.

3Thisshouldbethefullnameofthemainapplicantasgiveninhisorherpassportortraveldocument.

4Dateofbirth-forexample,3January1980shouldbewritten03011980inthespaces provided.

5Ifyoudonotselectafeethenwecannottakeapaymentandyourapplicationwillberejectedas invalid.


9Thenameasdisplayedonthecredit/debitcard

10Cardnumber-thisisthelongnumberacrossthecentreofthecard

11Thecardsecuritynumberisathree-digit securitycodeknownasthecardverificationvalue(CVV).Itconsistsofthelastthreenumbersonthesignaturestriponthebackofthecardasshownbelow.ForAmexthesecuritycodeconsistsof4digitsandisfoundonthefrontofthecard.

IfyoudonotprovidetheCVVnumber,wecannottakethepaymentandyourapplicationwillberejectedasinvalid.

12Cardholder’ssignature-thepersonnamedonthecredit/debitcardmustsignanddatethesesections.

4567123AUTHORISEDSIGNATURE

CVV123

AMERICAN EXPRESS

1234 1234 123456 12345

CVV 1234


Making sure your application is validTomakeavalidapplication,youmust:

•applyonline,orwiththisversionofformEEA(DRF1),unlesstherearecircumstancesbeyondyour control;

•paythespecifiedfeebyoneofthemethodssetoutinthePaymentGuidancesection;

•providephotographsofyourself,yourpartnerandanychildrenunder18whoareapplyingwithyouasspecifiedintheapplicationform;

•provideavalidpassport,nationalidentitycardortraveldocument,asrequired;

•providethenecessaryevidenceorprooftosupportyourapplication,asrequired(seeSection9forfurtherinformation);and

• complete the following sections of the form:

▪ Payment details

▪ Section1-Applicant’sdetails

▪ Section10-Declaration(s)

and,whererelevant:

▪ Biometricinformationfornon-EEAnationals

▪ Section1(C)-Familymembersincludedinyourapplicationform

Fornon-EEAnationalapplicants,andanynon-EEAnationalfamilymembersincludedintheapplication,youmustenrolyourbiometricdataincompliancewiththebiometricenrollmentletterthat we will send you after we have received your application.

If your application is rejected as invalidIfyoufailtodoanyofthesethings,forexample,ifthepaymentsubmitteddoesnotcoverthefullcostofyourapplication,orfailstomeettherequirementssetoutabove,yourapplicationwillberejectedasinvalid.

Thefeechargedisfortheprocessingandconsiderationoftheapplication.ThisfeewillbepayableoncetheapplicationformisreceivedbytheHomeOfficeoritspaymentprocessingagent,regardlessoftheoutcomeoftheapplication.

Wecannotbegintheconsiderationprocessuntilthepaymenthascleared.Weallow5workingdaysforpaymentsmadebychequetoclear,credit/debitcardsandpostalorderswillclearimmediately.

Ifyourapplicationisrejectedasinvalidyourapplicationwillnotbeconsideredandyourfeewillberefundedlessanadministrationfeeof£25foreachpersonincludedintheapplication.Wewillreturntheformwithanydocumentationsubmittedtoyou.Asthisisnotadecisiononwhetheryouqualifyforthedocumentationyouhaveappliedfor,youwillbeabletomakeanewapplication,correctinganyerrorsoromissions,andpayingthecorrectfee.


Thispageisintentionallyblank


Payment details - DRF1Pleasecompletethispageinblockcapitalsandblackinkafterfirstreadingthepaymentguidance.Itismandatorytocompletethissection.Ifitisnotcomplete,theapplicationwillbeinvalidandwillbereturnedtoyou.

1.ContactaddressintheUKforcorrespondence

Postcode

2.ContactnameintheUKifdifferentfromthatoftheapplicant

3. Full name as given in your passport or travel document.

4.DateofBirth D D M M Y Y Y Y

5.Amount-pleaseticktheamountyouarepaying.Ifnofeeistickedwecannottakeapaymentandyourapplicationwillberejectedasinvalid.

Amounttopay-singleapplicant-£65

6.Howareyoupaying?Pleasetickabox.

Postal order Cheque Debitorcreditcard Banker’sdraft

7.Payingbycheque/bankersdraft-pleasegivechequedetailsbelow(payableto‘HomeOffice’)Chequenumber Accountnumber Sort code

- -

8.Whichcardareyouusingforpayment?Pleasetickabox

Visa/Electron Mastercard/Amex Maestro/Solo Delta

9.Nameoncard

10.Cardnumber

Valid from Expirydate CVVnumber IssueNo.if11. Card details / / available

12.Cardholderssignature Date


Thispageisintentionallyblank


Biometric information for non-EEA nationals: form DRF1

Note:thissectionappliestonon-EEAnationalsapplyingforaderivativeresidencecardonly.DonotcompletethissectionifyouareanEEAnationalapplyingforaderivativeresidencecard–proceed straight to section 1 instead.

Ifyouareanon-EEAnationalapplyingforaderivativeresidencecard,youmustcompletethissectioninfull.Ifyoudonot,wemayrejectyourapplicationandreturnittoyouwithoutconsideration.

Introduction

InaccordancewiththeImmigration(ProvisionofPhysicalData)Regulations2006(asamended),anynon-EEAnationalapplyingforaderivativeresidencecardasevidenceoftheirrighttoresideundertheImmigration(EuropeanEconomicArea)Regulations2016(‘theEEARegulations’)mustgivetheirbiometricinformation(fingerprintsandadigitalphotograph)beforetheirapplicationwillbeconsidered.Youmustcompletethissectionfullytoensurethatwehavethecorrectinformationwhenyouattendyourbiometricappointment.

Whenwereceiveyourapplication,wewillsendyouabiometricenrolmentletter.ThiswillinstructyoutomakeanappointmentatadesignatedPostOfficetohaveyourbiometricinformationrecorded.Youwillbechargedanadditionalhandlingfeeforthisservice,payabletothePostOfficeLtd.Youmustpaythefeebycashordebitcardwhenyouattendyourbiometricenrolment appointment.

Do not send the biometric enrolment fee with your application fee.

Yourapplicationmayberejectedasinvalidifyoudonotenrolyourbiometricinformationwhenrequested.Formoreinformationaboutbiometrics,pleasevisitwww.gov.uk/biometric-residence-permits

Definitions

Inthissection,theterm‘residencecard(biometricformat)’meansaresidencecard,permanentresidence card or derivative residence card issued under the EEA Regulations after you have givenyourbiometricinformation.Thisisissuedasaseparatebiometriccardandnotasavignetteorstickerinyourpassport,traveldocument,orotherdocument.

Ifyoucurrentlyhave,orlasthad:

•aresidencecard(biometricformat)confirmingyourrighttoresideundertheEEARegulations,or

•abiometricresidencepermitconfirmingthatyouhadbeengrantedleavetoremainundertheImmigrationRulesorImmigrationAct1971,

youmustincludethisdocumentwithyourapplication(unlessyouhavealreadyreturnedthedocumenttous).

www.gov.uk/biometric-residence-permits

www.gov.uk/biometric-residence-permits


Your personal details

1. Yourtitle-pleasetick(Pleasestate)

Mr Mrs Miss Ms Master Other

Your full name:

Your nationality:

Yourdateofbirth: D D M M Y Y Y Y

Village,townorcityofbirth:

Countryofbirth:

YourhomeaddressintheUK:

Postcode

Current or previous residence card (biometric format) or biometric residence permit

2. Haveyoubeenissuedwitharesidencecard(biometricformat)orbiometricresidencepermit(BRP)inconnectionwithapreviousapplicationundertheEEARegulationsorforleavetoremain?

Yes go to question 3 No go to question 13

Note:ifyouwerelastissuedwitharesidencecardundertheEEARegulationsintheformavignetteorstickerinyourpassport,traveldocument,orotherdocument(suchasan‘immigrationstatusdocument’),answer‘no’totheabovequestion.


Ifyes,pleasegivedetailsofyourresidencecard(biometricformat)orBRPbelow.Youmustincludethisdocumentwithyourapplication,unlessitisnotavailableforoneofthereasonsspecifiedbelow.3. Residencecard(biometricformat)orBRPnumber:

4. Issuedate: D D M M Y Y Y Y

5. Expirydate: D D M M Y Y Y Y

6. Nationalityrecordedontheresidencecard(biometricformat)orBRP:

7. Place of issue:

8. Residencecard(biometricformat)orBRPenclosed?

Yes No

Ifnotenclosedthenpleasestatewheretheresidencecard(biometricformat)orBRPisnow:

ReturnedtoHomeOffice-gotoquestion9

Stolen-gotoquestion10

Lost-gotoquestion11

Other-gotoquestion12

9. Iftheresidencecard(biometricformat)orBRPhasbeenreturnedtotheHomeOffice,pleasegivedetailsbelow.

Reason it was returned:

Date it was returned: D D M M Y Y Y Y

10. Iftheresidencecard(biometricformat)orBRPwasstolen,pleasegivedetailsbelow.

Policereportnumber:


Crimereferencenumber:

Police station:

Date reported to the police:D D M M Y Y Y Y

DatereportedtotheHomeOfficecardmanagementservice:D D M M Y Y Y Y

11. Iftheresidencecard(biometricformat)orBRPwaslost,pleasegivedetailsbelow.

Date it was lost: D D M M Y Y Y Y

Whereitwaslost:

DatereportedtotheHomeOfficecardmanagementservice:D D M M Y Y Y Y

12.Iftheresidencecard(biometricformat)orBRPisnotenclosedforanyotherreason,pleaseexplainwhyyouareunabletoprovideitbelow:

Fingerprints in previous immigration applications13. HaveyouhadyourfingerprintstakenaspartofapreviousUKimmigrationapplicationmade

intheUKorabroad(includingforanEEAfamilypermit)?Yes continuebelow No gotoquestion14

Pleasegivedetailsbelowforeachcase.Ifyouneedmorespace,continueonaseparatesheetand enclose it with this application form.Thenameinwhichyourfingerprintsweretaken

Date on which theyweretaken(DD/MM/YYYY)

Place at which they weretaken

Britishdiplomaticpostiftheyweretakenabroad


Special arrangements for medical conditions

14.Do you have a medical or physical condition which may require special arrangements for yourbiometricfeaturestoberecorded?

Yes Please provide us with a letter from a treating clinician registered with the GeneralMedicalCouncil(GMC)givingdetailsoftheconditionand/orspecialneedsandexplaininganyarrangementsthatmaybenecessary.

No

Applicants under the age of 16

15.Areyouundertheageof16?Yes answer questions

16to18No gotoquestion19

16.Anychildundertheageof16mustbeaccompaniedbyaresponsibleadultwhentheyattendtheirbiometricappointment.Pleasegivedetailsofthepersonwhowillbeaccompanyingyouwhenyouattendyourbiometricappointment.

Nameofresponsibleadult:

Dateofbirthofresponsibleadult: D D M M Y Y Y Y

Nationalityofresponsibleadult:

Relationshipofresponsibleadulttoyou:

17.Istheresponsibleadultyourparentorlegalguardian?

Yes gotoquestion19 No gotoquestion18

Note:Theresponsibleadultaccompanyinganychildundertheageof16willneedtoprovideaformofphotographicidentification,suchasapassportorUKphotodrivinglicence.Ifthatpersonisnottheparentorguardianofthechild,theymusthavealetterconfirmingthattheyarearesponsibleadultwhohasacloseconnectiontothechildandhasbeenauthorisedtoaccompany him or her.


18.Pleaseexplainwhyyourparentorlegalguardianwillnotbeaccompanyingyoutotheap-pointment:

Declaration

19.AsrequiredbytheImmigration(ProvisionofPhysicalData)Regulations2006(asamended),IconfirmthatIamapplyingforaresidencecard(biometricformat)formyself.IfIamasoleapplicantundertheageof16,IunderstandthattheHomeOfficemaymakeenquiriesaboutanyresponsibleadultnominatedtobepresentwhenmyfingerprintsand/oraphotographaretaken.

Signed Date D D M M Y Y Y Y

Nowgotosection1.


Section 1 - Applicant’s detailsYoumustcompletethissectionasrequired,evenifyouhavealreadycompletedthebiometricsection.Ifyoudonot,yourapplicationwillbeinvalidandwillbereturnedtoyou.

A. Category of application1.1 Whichcategoryareyouapplyingforaderivativeresidencecardunder?Pleasetick:

PrimarycarerofaBritishcitizenchildordependentadult(‘Zambrano’)

PrimarycarerofanEEAnationalchildwhoisexercisingtheirTreatyrightsasaself-sufficientperson(‘Chen’)

ChildofanEEAnationalworkerorformerworkerwherethechildisineducationintheUK(‘IbrahimandTexeira’)

PrimarycarerofachildofanEEAnationalworkerorformerworkerwherethechildisineducationintheUK(‘IbrahimandTeixeira’)

Dependentchildagedunder18ofaprimarycarerinoneofthecategoriesabove.

B. Your personal details

Photographs-Youmustprovidetworecentidenticalphotographsofyourselfwithyourfullnameonthebackofeachone.Pleaseplacethephotographsinasmallsealedenvelopeandattachitwithastapleorpaperclipattheright-handside.

Pleasemakesurethatthestapleorpaperclipdoesnotdamageormarkthephotographs.

Allphotographsmustbeasspecifiedinthephotographguidance.Acopyofthephotographguidancecanbefoundat:www.gov.uk/photos-for-passports

Your name1.2 Yourtitle-pleasetick

(Pleasestate)Mr Mrs Miss Ms Master Other

1.3 Yourfullnameasshowninyourpassport,traveldocumentorEEAnationalidentitycard

1.4 Surnameorfamilynameasshowninyourpassport,traveldocumentorEEAnationalidentity card

https://www.gov.uk/photos-for-passports


1.5 Anyothername(s)bywhichyouareorhavebeenknownName(s) Dates during which you have

usedthis/thesename(s)

1.6 Ifyouhavechangedyourname,whydidyouchangeit?

Marriage/civilpartnership Divorce

Other(pleasestate)

Your gender and relationship status

1.7 Whatisyourgender? Male Female

1.8 Whatisyourrelationshipstatus?

Married Dissolved civil partnership

Civil partner Surviving civil partner

Single Unmarried partner

Divorced Separated

Widow/widower Separation order

Your date of birth, place of birth and nationality

1.9 Yourdateofbirth D D M M Y Y Y Y

1.10 Village,townorcityofbirth

1.11 Countryofbirth

1.12 Yourcurrentnationality(asstatedinyourpassport,traveldocumentornationalidentitycardifyouareanEEAnational)


1.13 Doyoucurrentlyhold,orhaveyoueverheld,anyothernationalityorcitizenship?

Yes No

1.14 IfYes,pleasegivedetailsbelow:Nationality or citizenship Dates held

From (DD/MM/YYYY) To (DD/MM/YYYY)*

*Ifyoustillholdtherelevantnationalityorcitizenship,pleasewrite‘present’.

Your passport or national identity card

1.15 Pleasegivedetailsofyourcurrentpassport,traveldocumentor(ifyouareanEEAnational)nationalidentitycardinthetablebelow.

Passport or travel document

National identity card (EEA national only)

Documentreferencenumber

Place of issue

Issuingauthority

Date of issue

Expirydate

1.16 Areyousubmittingavalidpassport,traveldocumentor(ifyouareanEEAnational)nationalidentitycardwiththisapplication?

Yes,validpassport Yes,validtraveldocument

Yes,validnationalidentitycard No

1.17 Ifyouhaveanswerednotoquestion1.16,pleasesaywhynotintheboxbelowandsubmitanyrelevantsupportingevidence

Reason(s)fornotsubmittingavalidpassport,traveldocumentornationalidentitycard:


Unlessyourvalidpassport,traveldocumentornationalidentitycardisalreadywiththeHomeOffice,youmustalsosubmitalternativeevidenceofyouridentityandnationality.Pleasesaywhatthisevidenceisintheboxbelow

Please note: we will only accept alternative evidence of your identity and nationality if you can showthatyouarenotabletosubmitavalidpassport,traveldocumentornationalidentitycardduetocircumstancesbeyondyourcontrol.

Your personal reference numbers

1.18 HomeOfficereferencenumber(s):

1.19 UKnationalinsurancenumber:

1.20 Biometricresidencepermitnumber:

1.21 Residencecardnumber:

1.22 AnyotherHomeOfficereferencenumber:

Ifyoudonothaveanyoftheabovereferencenumbers,pleasewrite‘N/A’(notapplicable)intherelevantboxorleaveitblank.

Your contact details

1.23 YourhomeaddressintheUK:

Postcode

1.24 YournameandaddressintheUKforallcorrespondenceifdifferentfromyourhomeaddress:

Postcode


1.25 Istheaddressin1.24theaddressofyourrepresentativeorauthorisedimmigrationadviser?

Yes No Notapplicable

1.26 Yourhome/daytimetelephonenumber 1.27 Yourmobilenumberifyouhaveone

1.28 Your email address and that of your representative if you have one. Please write your emailaddressclearlyinblockcapitalsandnotethatwecanonlysendupdatestotheemailaddress you provide.

Your email address:

Pleasere-enteryouremailaddressinblockcapitals:

Your representative’s email address:

TheHomeOfficeorpersonsactingonbehalfoftheHomeOfficemayusetheaboveemailaddress(es)tocommunicatewithyouaboutyourapplication.Youmustcheckyouremailaccountatregularintervalsandrespondtoanyfurtherinformationrequestsassoonaspossible.


C. Family members applying with youIfyouhaveanyfamilymembersorrelativesapplyingforaderivativeresidencecardatthesametimeasyou,pleaseentertheirdetailsbelow.Thiswillhelpuskeepyourapplicationstogether.Continue on a separate sheet if necessary.

Please note that each person applying for a derivative residence card must complete their own applicationformandpaythespecifiedapplicationfee.

Westronglyrecommendthatyouencloseallapplicationsinthesameenvelopeifyouwantthemtobeconsideredtogether.

Full name Nationality Date of birth (DD/MM/YYYY)

Document applied for

Nowgotosection2.


Section 2 - Primary carer of a British citizen child or dependent adult (‘Zambrano’)Youmustalsocompletesections7-10

2.1 PleasetickoneofthefollowingboxestoconfirmwhethertheBritishcitizenofwhomyouare the primary carer is:

aBritishcitizenchildagedunder18

adependentBritishcitizenadultaged18orover

2.2 Pleasetickoneofthefollowingboxestoconfirmwhetheryouareapplyingas:

thesoleprimarycarerofaBritishcitizen

ajointprimarycarerwhosharescaringresponsibilityforaBritishcitizenequallywithanotherperson

A. The British citizen’s personal detailsPhotographsEncloseapassport-sizedphotographoftheBritishcitizenforwhomyouaretheprimarycarerwiththeirfullnamewrittenclearlyontheback.

Please place the photograph in a small sealed envelope and attach it with a staple or paper clip attheright-handside.

Pleasemakesurethatthestapleorpaperclipdoesnotdamageormarkthephotograph.


British citizen’s name2.3 Title-pleasetick


2.4 Full name as shown in their passport

2.5 Surname or family name as shown in their passport



2.6 Anyothername(s)theyareorhavebeen,knownby

Name(s) Dates during which they have usedthis/thesename(s)

2.7 Iftheyhavechangedtheirname,whydidtheychangeit?


Other(pleasestate)

British citizen’s gender and relationship status

2.8 Whatistheirgender? Male Female

2.9 Whatistheirrelationshipstatus?Married Dissolved civil partnership



Divorced Separated


Other(pleasestate)

British citizen’s place of birth, date of birth and nationality


2.11 Countryofbirth


2.12 DotheyholdBritishcitizenship?

Yes No

2.13 EvidenceofBritishcitizenshipsubmitted:

currentBritishcitizenpassport

passportnumber:

certificateofregistrationasaBritishcitizenissuedbytheHomeOffice

nationalitystatusletterissuedbytheHomeOfficeconfirmingBritishcitizenstatus

certificateofnaturalisationasaBritishcitizenissuedbytheHomeOffice

certificateofentitlementtoarightofabodeintheUnitedKingdomissuedundersection2(1)(a)oftheImmigrationAct1971

UKbirthcertificateshowingbirthintheUKbefore1January1983

UKbirthcertificateshowingbirthintheUKonorafter1January1983andevidencethateitherparentwaseitheraBritishcitizenorsettledintheUKatthetimeofthebirth.

Pleasenote:BirthintheUKonorafter1January1983doesnotautomaticallyconferBritishcitizenship.Asstatedabove,youmustalsoshowthateitherparentwaseitheraBritishcitizenorsettledintheUKatthetimeofthebirth.

2.14 Dateofbirth D D M M Y Y Y Y

2.15 Dotheycurrentlyhold,orhavetheyeverheld,anyothernationalityorcitizenship?

Yes No




*Iftheystillholdtherelevantnationalityorcitizenship,pleasewrite‘present’.

British citizen’s contact details

2.17 PleasegivetheBritishcitizen’shomeaddressintheUK,ifdifferentfromtheaddressgiven in section 1.

Postcode

B. Your relationship to the British citizen

2.18 PleasetickoneofthefollowingboxestoindicateyourrelationshiptotheBritishcitizenofwhom you are the primary carer:

parent

legal guardian

grandparent

spouse or civil partner

child

grandchild

sibling

Pleasenote–ifyouarenotinoneofthecategoriessetoutabove,youwillnotqualifyforarightofresidenceastheprimarycarerofaBritishcitizen.

Pleaseseesection9forinformationonevidencethatcanbesubmittedtodemonstrateyourrelationshiptotheBritishcitizen.


C. Dependency

2.19 PleasegivedetailsabouthowtheBritishcitizeniswhollyreliantonyou(oryouandyourjointprimarycarer)fortheircare(forexample,financialdependence,personalcare):

2.20 IsthereanotherpersonintheUKwhocouldordoesassumecaringresponsibilityfortheBritishcitizen?

Yes-givedetails No

2.21 PleasegivedetailsofanyotherrelativesoftheBritishcitizenwhoarelivingintheUK:Full name Dateofbirth Nationality RelationshiptotheBritish

citizen


Parent(s) of the British citizen child aged under 18

IfyouareapplyingastheprimarycareroftheBritishcitizenagedunder18,andyouarenottheirparent,pleasecompletethissectionforbothparentsoftheBritishcitizen.

IfyouaretheBritishcitizen’sparent,andthechild’sotherparentisnotapplyingforaderivativeresidencecard(andhasnotalreadybeenissuedwithaderivativeresidencecard),pleasecomplete this section for the other parent.

Mother Father2.22 Full name

2.23 Dateofbirth2.24 Nationality2.25 Immigrationstatus

2.26 Currentaddress(orlastknowaddress)

2.27 Whatsortofcontact(includingfacetoface,bytelephoneoranyothermeans)does the child have with this parent?2.28 How often does this contacttakeplace?(Forexample,onceaweek,twiceamonth)2.29 Whenwasthelastknowncontactbetweenthechildandthisparent?2.30 IsthereaformalCourtorderinplaceforthechild(forexample,acustodyagreement,residence order or contact order)?Ifso,pleaseprovideacopyofthisagreement/order.2.31 Does this parent provide anyfinancialsupportormaintenance payments for the child?2.32 Ifyouhaveansweredyestoquestion2.31,pleaselistthese payments and the amount received per month


Primary carer of dependent British adult aged 18 or over

IfyouaretheprimarycarerofadependentBritishcitizenaged18orover,pleasecompletethefollowing section.

2.33 WhatisthenatureofthecarethatyouprovidetotheBritishcitizen?

2.34 HowmanyhoursofcaredoyouprovidefortheBritishcitizeneachweek?

2.35 Whatdatedidyoustartprovidingthiscare? D D M M Y Y Y Y

2.36 WhowasprovidingcaretotheBritishcitizenbeforethisdate?

2.37 Pleaseexplainwhythepreviouscarearrangementscouldnotcontinue

2.38 DoestheBritishcitizencurrentlyreceivecarefromanybodyelse(forexample,anotherperson,thelocalauthorityoraprivatecareprovider?)

Yes No

2.39 Ifyouhaveansweredyestoquestion2.38above,pleasegivedetailsofwhoprovidesthiscare,whatcareisprovided,andforhowmanyhourseachweek?

2.40 Ifyouhaveanswerednotoquestion2.38above,pleasegivedetailsofwhatenquirieshavebeenmadeastowhethersuchcarecanbeprovided?


D. Other primary carer

IfthereisanotherpersonintheUKwho:

•isapplyingforaderivativeresidencecardastheprimarycareroftheBritishcitizenatthesametimeasyou,

• has an outstanding application for a derivative residence card as the primary carer of the Britishcitizen,

•hasbeenissuedwithaderivativeresidencecardastheprimarycareroftheBritishcitizen,or

•isrelyingonaderivativerightofresidenceintheUKonthebasisthattheyaretheprimarycareroftheBritishcitizen;

you must complete the following section in relation to that person.

2.41 Theirtitle-pleasetick(Pleasestate)


2.42 Theirnameasintheirpassport(ornationalIDcardiftheyareanEEAnational)

2.43 Theirsurnameasintheirpassport(ornationalIDcardiftheyareanEEAnational)

2.44 Anyothername(s)bywhichtheyareorhaveeverbeenknown.Name(s) Dates during which they have


2.45 Theirdateofbirth D D M M Y Y Y Y


2.47 Whatistheirnationality?


2.48 Theirplaceofbirth–townorcityandcountry

2.49 Theirpassportortraveldocumentnumber

2.50 Theirimmigrationstatus(ifapplicable)

2.51 TheirHomeOfficereference(ifapplicable)

2.52 TheirUnitedKingdomaddress

Postcode

2.53 TheirrelationshiptotheBritishcitizen:

2.54 Theirrelationshiptoyou:

2.55 Aretheyalsoapplyingforaderivativeresidencecard?

Yes No

Pleasenotethatiftheotherprimarycarerwishestoapplyforaderivativeresidencecard,theymustcompletetheirownapplicationformandpaythespecifiedapplicationfee.

Westronglyrecommendthatyouencloseallapplicationsinthesameenvelope,andincludedetails of all applicants in section 1C of each application form.


Section 3 - Primary carer of an EEA national child who is exercising Treaty rights in the UK as a self-sufficient person (‘Chen’)

IfyouareapplyingastheprimarycarerofanEEAnationalchildundertheageof18whoisexercisingTreatyrightsintheUKasaself-sufficientpersonpleasecompletethissectioninfull.Ifyoudonot,yourapplicationmaybedelayedorrefused.

Youmustalsocompletesections7-10


thesoleprimarycarerofaself-sufficientEEAnationalchild

ajointprimarycarerwhosharescaringresponsibilityforaself-sufficientEEAnationalchildequally with another person

A. The EEA national child’s personal detailsPhotograph(s)Encloseapassport-sizedphotographoftheEEAnationalchildforwhomyouaretheprimarycarerwiththeirfullnamewrittenclearlyontheback.




EEA national child’s name3.2 Title-pleasetick


3.3 Full name as shown in their passport or EEA national identity card

3.4 Surname or family name as shown in their passport or EEA national identity card

www.gov.uk/photos-for-passports


3.5 Anyothername(s)theyareorhavebeen,knownby




Other(pleasestate)

EEA national child’s gender and relationship status


3.8 Whatistheirrelationshipstatus?




Divorced Separated


Other(pleasestate)

EEA national child’s place of birth, date of birth and nationality


3.10 Countryofbirth

3.11 Nationality


3.12 EvidenceofEEAnationalitysubmitted:

validpassportissuedbyanEEAstate

validEEAnationalIDcard

PassportorIDcardnumber:

3.13 DotheyhavearegistrationcertificateissuedbytheHomeOffice?

Yes No

3.14 Ifyouhaveansweredyestoquestion3.13above,pleasegivetheregistrationcertificatenumber

3.15 DotheyalsoholdBritishcitizenship?

Yes No


Yes No



*Ifrelevantnationalityorcitizenshipstillheld,pleasewrite‘present’.


EEA national child’s contact details

3.19 PleasegivetheEEAnationalchild’shomeaddressintheUK,ifdifferentfromtheaddressgiven in section 1.

Postcode


B. Your relationship to the EEA national child3.20 PleasetickoneofthefollowingboxestoindicateyourrelationshiptotheEEAnationalchild of whom you are the primary carer:

parent

legal guardian

grandparent

sibling

Pleasenote–ifyouarenotinoneofthecategoriessetoutabove,youwillnotqualifyforarightofresidenceastheprimarycarerofaself-sufficientEEAnationalchild.

Pleaseseesection9forinformationonevidencethatcanbesubmittedtodemonstrateyourrelationship to the EEA national child.

C. Evidence that the child is self-sufficientSufficient resourcesPleaseenterthedatetheEEAnationalchildstartedlivingintheUKasaself-sufficientperson

D D M M Y Y Y Y

3.21 PleaseindicatebelowhowtheEEAnationalchildmeetstherequirementtohavesufficientfinancialresourcestosupportthemselvesandtheirprimarycarer(s)withoutneedingtoclaimbenefits/publicfunds.Pleaseprovideamountsforallthatapply.

Type of financial resource

Owner of financial resource

EEA national child Family member living in the UK

Other relative (not in the UK), friend or

other personSavings

Investments

IncomefromrentalpropertyState pension

Occupational pension

IncomefromlawfulemploymentIncomefromlawfulself-employmentOther-pleasestate

Pleaseseesection9forinformationonevidencethatcanbesubmittedtodemonstratetheresourcesavailabletotheEEAnationalchild


Comprehensive sickness insurance cover

3.22 PleaseindicatebelowhowtheEEAnationalchildmeetstherequirementtohavecomprehensivesicknessinsuranceforthemselves(andtheirprimarycarer(s)).

Tickallthatapply:

Private medical insurance

EuropeanHealthInsuranceCard(EHIC)*issuedbyanEEAMemberState(nottheUK)

Form S1

FormS2

Form S3

*YoucanonlyrelyonanEHICifyouhavenotcometolivepermanentlyintheUK.AswellassubmittingyourEHIC,youmustalsosubmita‘statementofintent’confirmingthatyoudonotintendtolivepermanentlyintheUK.

Pleaseseesection9forinformationonevidencerequiredtodemonstratecomprehensivesicknessinsurance.

D. Dependency

3.23 PleasegivedetailsabouthowtheEEAnationalchildiswhollyreliantonyou(oryouandyourjointprimarycarer)fortheircare(forexample,financialdependence,personalcare):

3.24 IsthereanotherpersonintheUKwhocouldordoesassumecaringresponsibilityfortheEEAnationalchild?

Yes-givedetails No


3.25 Please give details of any other relatives of the EEA national child who are living in the UK:Full name Dateofbirth Nationality RelationshiptotheBritish

citizen

Parent(s) of the EEA national child

IfyouareapplyingastheprimarycareroftheEEAnationalchild,andyouarenottheirparent,pleasecompletethissectionforbothparentsoftheEEAnationalchild.

IfyouaretheEEAnationalchild’sparent,andthechild’sotherparentisnotapplyingforaderivativeresidencecard(andhasnotalreadybeenissuedwithaderivativeresidencecard),please complete this section for the other parent.

Mother Father

3.26 Full name

3.27 Dateofbirth

3.28 Nationality

3.29 Immigrationstatus

3.30 Currentaddress(orlastknowaddress)3.31 Whatsortofcontact(includingfacetoface,bytelephoneoranyothermeans)does the child have with this parent?3.32 How often does this contacttakeplace?(Forexample,onceaweek,twiceamonth)3.33 Whenwasthelastknowncontactbetweenthechildandthisparent?


3.34 IsthereaformalCourtorderinplaceforthechild(forexample,acustodyagreement,residence order or contact order)?Ifso,pleaseprovideacopyofthisagreement/order.3.35 Does this parent provide anyfinancialsupportormaintenance payments for the child?3.36 Ifyouhaveansweredyestoquestion3.35,pleaselistthese payments and the amount received per month

E. Other primary carer


• is applying for a derivative residence card as the primary carer of the EEA national child at the sametimeasyou,

• has an outstanding application for a derivative residence card as the primary carer of the EEA nationalchild,

•hasbeenissuedwithaderivativeresidencecardastheprimarycareroftheEEAnationalchild,or

•isrelyingonaderivativerightofresidenceintheUKonthebasisthattheyaretheprimarycarer of the EEA national child;


3.37 Theirtitle-pleasetick

Mr Mrs Miss Ms Master

3.38 If‘other’,whatistheirtitle?




3.41 Anyothername(s)bywhichtheyareorhaveeverbeenknown.










Postcode


3.50 TheirrelationshiptotheEEAnationalchild:

parent

legal guardian

grandparent

aunt or uncle

brotherorsister

spouse or civil partner



Yes No

Nowgotosection4.


Section 4 - Child of an EEA national former worker where the child is in education in the UK (Ibrahim/Teixeira)IfyouareapplyingasthechildofanEEAnationalformerworkerandyouareineducationintheUK,pleasecompletethissectioninfull.Ifyoudonot,yourapplicationmaybedelayedorrefused.


IfyouareapplyingastheprimarycarerofachildofanEEAnationalformerworkerwherethatchildisineducationintheUK,youmustcompletethissectionandsection5.


Please note that if the child for whom you are a primary carer wishes to apply for a derivative residencecard,aseparateapplicationformandthespecifiedapplicationfeemustbesubmittedfor that child.


A. Your residence in the UK

4.1 WhatdatedidyoustartlivingintheUK?

D D M M Y Y Y Y

Frombirth

4.2 PleasegivedetailsofanytimesatwhichyouhavebeenabsentfromtheUK(fromthedateonwhichyoustartedlivingintheUK)

Country or countries visited Date of departure from UK

Date of return to UK

Number of days absent


B. Your education in the UK

4.3 AreyoucurrentlyineducationintheUK?

Yes No

4.4 Pleasegivethenameandaddressofyourcurrentschool,collegeorothereducationalestablishmentbelow:

Postcode

4.5 Ifyouarenotinprimaryorsecondaryeducation,whatcourseofeducationareyouattending?

4.6 Ifyouarenotinprimaryorsecondaryeducation,whenareyouduetocompleteyourcourse?

D D M M Y Y Y Y

4.7 WhendidyoufirstentereducationintheUK?

D D M M Y Y Y Y

Please note that ‘education’ does not include nursery education.

4.8 Pleasegivedetailsoftheeducationalestablishments(ifdifferentfromtheansweryouhavegivenatquestion4.4)whichyouhaveattendedsinceenteringeducationintheUK:

Name and address of establishment Start date End date Course attended


C. The EEA national former worker’s personal details

EEA national’s name

4.9 Title-pleasetick(Pleasestate)


4.10 Full name as shown in their passport or EEA national identity card

4.11 Surname or family name as shown in their passport or EEA national identity card

4.12 Anyothername(s)theyareorhavebeen,knownbyName(s) Dates during which they have




Other(pleasestate)

4.14 Theirdateofbirth

D D M M Y Y Y Y

EEA national’s gender and relationship status






Divorced Separated


Other(pleasestate)

EEA national’s place of birth and nationality


4.18 Countryofbirth

4.19 Nationality

4.20 EvidenceofEEAnationalitysubmitted:

validpassportissuedbyanEEAstate

validEEAnationalIDcard

4.21 PassportorIDcardnumber:

4.22 Dotheyhave,ordidtheyeverhavearegistrationcertificateissuedbytheHomeOffice?Yes No

4.23 Ifyouhaveansweredyestoquestion4.21above,pleasegivetheregistrationcertificatenumber

4.24 DotheyalsoholdBritishcitizenship?

Yes No



Yes No

4.26 IfYes,pleasegivedetailsbelow:

Nationality or citizenship Dates heldFrom (DD/MM/YYYY) To (DD/MM/YYYY)*

*Ifrelevantnationalityorcitizenshipstillheld,pleasewrite‘present’.

EEA national contact details

4.27 PleasegivetheEEAnational’shomeaddressintheUK,ifdifferentfromtheaddressgiven in section 1.

Postcode

4.28 Ifyoudonotknowtheircurrentaddress,pleaseprovidethelastknownaddressfortheEEA national:

Postcode

D. Your relationship to the EEA national former worker

4.29 Pleasetickoneofthefollowingboxestoindicatewhichevidenceyouhavesubmittedtodemonstrate your relationship to the EEA national.

Birthcertificate

Adoptioncertificate

Pleaseseesection9forfurtherinformationonevidenceyoucansubmittodemonstrateyourrelationship to the EEA national


E. The EEA national former worker’s residence in the UK

4.30 WhatdatedidtheEEAnationalformerworkerstartlivingintheUK?

D D M M Y Y Y Y

4.31 IstheEEAnationalformerworkerstilllivingintheUK?

Yes No

4.32 Ifyouhaveanswerednotoquestion4.31above,whatdatedidtheEEAnationalformerworkerleavetheUK?

D D M M Y Y Y Y

4.33 PleasegivedetailsofanytimesatwhichtheEEAnationalformerworkerwasabsentfromtheUKfromthedateatwhichtheystartedlivingintheUK:

Country or countries visited Date of departure

from the UK

Date of return to the UK

Number of days absent

F. The EEA national former worker’s employment

4.34 DidyourEEAnationalparentexerciseTreatyrightsasaworkerintheUKatatimewhenyouwerealsoresidingintheUK?

Yes No

4.35 Pleasegivedetailsofthetime(s)whenyourEEAnationalparentwasexercisingTreatyrightsintheUKasaworker:Nameandaddressofemployer From To

Youmustalsoprovideevidenceofthisemployment–pleaseseesection9forfurtherinformationontheevidenceyoucansubmittodemonstratethatyourEEAnationalparentwasaworker.


Section 5 - Primary carer of a child of an EEA national former worker where the child is in education in the UK (‘Ibrahim/Teixeira’)IfyouareapplyingastheprimarycarerofachildofanEEAnationalformerworkerwherethatchildisineducationintheUK(‘thechild’),youmustcompletethissectionandsection4ofthisform.Ifyoudonot,yourapplicationmaybedelayedorrefused.


Please note that if the child for whom you are a primary carer wishes to apply for a derivative residencecard,aseparateapplicationformandthespecifiedapplicationfeemustbesubmittedfor that child.



the sole primary carer of the child

ajointprimarycarerwhosharescaringresponsibilityforthechildequallywithanotherperson

A. The child’s personal detailsPhotograph(s)Encloseapassport-sizedphotographofthechildforwhomyouaretheprimarycarerwiththeirfullnamewrittenclearlyontheback.




The child’s name5.2 Title-pleasetick


5.3 Fullnameasshownintheirpassport(ornationalidentitycard,iftheyareanEEAnational)

5.4 Surnameorfamilynameasshownintheirpassport(ornationalidentitycard,iftheyareanEEAnational)







Other(pleasestate)

The child’s gender and relationship status





Divorced Separated


Other(pleasestate)

The child’s place of birth, date of birth and nationality


5.10 Countryofbirth

5.11 Nationality



Yes No





Child’s contact details

5.15 Pleasegivethechild’shomeaddressintheUK,ifdifferentfromtheaddressgiveninsection 1.

Postcode

B. Your relationship to the child

5.16 Pleasetickoneofthefollowingboxestoindicateyourrelationshiptothechildofwhomyou are the primary carer:

parent

legal guardian

grandparent

sibling

Pleasenote–ifyouarenotinoneofthecategoriessetoutabove,youwillnotqualifyforarightofresidenceastheprimarycarerofachildofanEEAnationalformerworker.

Pleaseseesection9forinformationonevidencethatcanbesubmittedtodemonstrateyourrelationship to the child.


C. Dependency

5.17 Pleasegivedetailsabouthowthechildiswhollyreliantonyou(oryouandyourjointprimarycarer)fortheircare(forexample,financialdependence,personalcare):

5.18 IsthereanotherpersonintheUKwhocouldordoesassumecaringresponsibilityforthechild?

Yes-givedetails No

5.19 Please give details of any other relatives of the EEA national child who are living in the UK:Full name Dateofbirth Nationality RelationshiptotheBritish

citizen

Parent(s) of the child

Ifyouareapplyingastheprimarycarerofthechild,andyouarenottheirparent,pleasecompletethissectionforbothparentsofthechild.

IfyouaretheBritishcitizen’sparent,andthechild’sotherparentisnotapplyingforaderivativeresidencecard(andhasnotalreadybeenissuedwithaderivativeresidencecard),pleasecomplete this section for the other parent.

Mother Father5.20 Full name5.21 Dateofbirth5.22 Nationality5.23 Immigrationstatus5.24 Currentaddress(orlastknowaddress)


5.25 Whatsortofcontact(includingfacetoface,bytelephoneoranyothermeans)does the child have with this parent?5.26 How often does this contacttakeplace?(Forexample,onceaweek,twiceamonth)5.27 Whenwasthelastknowncontactbetweenthechildandthisparent?5.28 IsthereaformalCourtorderinplaceforthechild(forexample,acustodyagreement,residence order or contact order)?Ifso,pleaseprovideacopyofthisagreement/order.5.29 Does this parent provide anyfinancialsupportormaintenance payments for the child?5.30 Ifyouhaveansweredyestoquestion5.29,pleaselistthese payments and the amount received per month

Primary carer of child in education aged 18 or over

Ifthechildforwhomyouaretheprimarycarerisaged18orover,pleasecompletethefollowingsection.

5.31 Whatisthenatureofthecarethatyouprovidetothechild?

5.32 Howmanyhoursofcaredoyouprovideforthechildeachweek?

5.33 Whatdatedidyoustartprovidingthiscare? D D M M Y Y Y Y

5.34 Whowasprovidingcaretothechildbeforethisdate?


5.35 Pleaseexplainwhythepreviouscarearrangementscouldnotcontinue

5.36 Doesthechildcurrentlyreceivecarefromanybodyelse(forexample,anotherperson,thelocalauthorityoraprivatecareprovider?)

Yes No

5.37 Ifyouhaveansweredyestoquestion5.36above,pleasegivedetailsofwhoprovidesthiscare,whatcareisprovided,andforhowmanyhourseachweek?

5.38 Ifyouhaveanswerednotoquestion5.36above,pleasegivedetailsofwhatenquirieshavebeenmadeastowhethersuchcarecanbeprovided?

D. Other primary carer


• is applying for a derivative residence card as the primary carer of the child at the same time asyou,

• has an outstanding application for a derivative residence card as the primary carer of the child,

•hasbeenissuedwithaderivativeresidencecardastheprimarycarerofthechild,or

•isrelyingonaderivativerightofresidenceintheUKonthebasisthattheyaretheprimarycarer of the child;



5.39 Theirtitle-pleasetick(Pleasestate)




5.42 Anyothername(s)bywhichtheyareorhaveeverbeenknown.Name(s) Dates during which they have










Postcode


5.51 TheirrelationshiptotheBritishcitizen:



Yes No

Pleasenotethatiftheotherprimarycarerwishestoapplyforaderivativeresidencecard,theymustcompletetheirownapplicationformandpaythespecifiedapplicationfee.



Section 6 - Dependent child of a primary carer who has a derivative right of residence in the UKIfyouareapplyingasthechildagedunder18ofaprimarycarerwithaderivativerightofresidenceintheUK,youmustcompletethissection.Ifyoudonot,yourapplicationmaybedelayed or refused.

6.1 PleasetickoneofthefollowingboxedtoindicatethebasisonwhichyourprimarycarerhasaderivativerightofresidenceintheUK:

astheprimarycarerofaBritishcitizenchildordependentadult

Youmustalsocompletesection2,andsections7-10

astheprimarycarerofanEEAnationalchildwhoisexercisingtheirTreatyrightsasaself-sufficientpersonintheUK

Youmustalsocompletesection3,andsections7-10

astheprimarycarerofachildofanEEAnationalformerworkerwherethatchildisineducationtheUK

Youmustalsocompletesections4and5and7-10

Pleasenotethatifyourprimarycarerwishestoapplyforaderivativeresidencecard,theymustcompletetheirownapplicationformandpaythespecifiedapplicationfee.


A. Your primary carer’s personal detailsPhotograph(s)Encloseapassport-sizedphotographofyourprimarycarerwiththeirfullnamewrittenclearlyontheback.




Your primary carer’s name

6.2 Title-pleasetick(Pleasestate)




6.3 Full name as shown in their passport

6.4 Surname or family name as shown in their passport





Other(pleasestate)

The primary carer’s gender and relationship status


6.8 Whatistheirrelationshipstatus?




Divorced Separated


Other(pleasestate)

The primary carer’s place of birth, date of birth and nationality



6.10 Countryofbirth

6.11 Nationality


Yes No





The primary carer’s contact details

6.15 Pleasegivethechild’shomeaddressintheUK,ifdifferentfromtheaddressgiveninsection 1.

Postcode

B. Your relationship to the primary carer

6.16 Pleasetickoneofthefollowingboxestoindicateyourprimarycarer’srelationshiptoyou:

parent

legal guardian

grandparent

sibling

Pleasenote–ifyourprimarycarerisnotinoneofthecategoriessetoutabove,youwillnotqualify for a right of residence as the dependant of a primary carer with a derivative right of residence.


Pleaseseesection9forinformationonevidencethatcanbesubmittedtodemonstrateyourrelationship to the primary carer.

C. Dependency

6.17 Pleasegivedetailsabouthowyouarewhollyreliantonprimarycarerforyourcare:

6.18 IsthereanotherpersonintheUKoranywhereelsewhocouldordoesassumecaringresponsibilityforyou?

Yes-givedetails No

Your Parents

Iftheprimarycarerisnotyourparent,pleasecompletethissectionforbothofyourparents.

Ifyourprimarycarerisyourparent,andyourotherparentisnotapplyingforaderivativeresidencecard(andhasnotalreadybeenissuedwithaderivativeresidencecard),pleasecomplete this section for the other parent.

Mother Father6.19 Full name

6.20 Dateofbirth

6.21 Nationality

6.22 Immigrationstatus

6.23 Currentaddress(orlastknowaddress)6.24 Whatsortofcontact(includingfacetoface,bytelephoneoranyothermeans)does the child have with this parent?


6.25 How often does this contacttakeplace?(Forexample,onceaweek,twiceamonth)6.26 Whenwasthelastknowncontactbetweenthechildandthisparent?6.27 IsthereaformalCourtorderinplaceforthechild(forexample,acustodyagreement,residence order or contact order)?Ifso,pleaseprovideacopyofthisagreement/order.6.28 Does this parent provide anyfinancialsupportormaintenance payments for the child?6.29 Ifyouhaveansweredyestoquestion6.28,pleaselistthese payments and the amount received per month


Section 7 - personal history (such as criminal convictions, war crimes)Thissectionasksyouaboutanycriminalconvictionsyouhave,anyciviljudgmentsorcivilpenaltiesmadeagainstyouanddetailsofanyinvolvementyoumayhavehadinwarcrimes,genocide,crimesagainsthumanityorterrorism.Ifyoufailtoanswerallofthesequestionsasfullyandaccuratelyaspossible,yourapplicationmayberefused.

Itisanoffenceundersection26(1)(c)oftheImmigrationAct1971tomakeastatementorrepresentationwhichisknowntobefalseorisnotbelievedtobetrue.Informationgivenwillbecheckedwithotheragencies.

7.1 HaveyoubeenconvictedofanycriminaloffenceintheUKoranyothercountry?

Yes -continuebelow No -gotoquestion7.2

Pleasegivedetailsbelowforeachcriminalconviction,startingwiththemostrecentone.Ifyouoranydependantswhoareapplyingwithyouhavereceivedmorethantwoconvictions,pleasephotocopy this page and enclose it with this form.

Note:Wewillcarryoutcriminalrecordchecksonallapplicantsanddependants.

Inaccordancewithsection56AoftheUKBordersAct2007youarerequiredtodiscloseallspentorunspentconvictions.Thisincludesroadtrafficoffencesbutnotfixedpenaltynotices(suchasspeedingorparkingtickets)unlesstheywerepartofasentenceofthecourt.Thisincludesalldrink-drivingoffences.

Criminal conviction 1

Nameunderwhichyouwereconvicted

Country where convicted

Natureoftheoffence

Sentence given

Date sentenced D D M M Y Y Y Y


Ifyouweresentencedtoaperiodofimprisonment,whatwasthelengthoftheprisonsentenceimposed(inmonths)?

months

Criminalconviction2

Nameunderwhichyouwereconvicted

Country where convicted

Natureoftheoffence

Sentence given

Date sentenced D D M M Y Y Y Y

Ifyouweresentencedtoaperiodofimprisonment,whatwasthelengthoftheprisonsentenceimposed(inmonths)?

months

7.2 DoyouhaveanyciviljudgmentsagainstyouoranycivilpenaltyundertheUKimmigrationacts?

Yes continuebelow No gotoquestion7.3

GivedetailsforeachciviljudgmentoranycivilpenaltyundertheUKimmigrationacts,startingwith the most recent one.Ifyouhavereceivedmorethantwociviljudgmentsand/orcivilpenaltiesundertheUKimmigrationacts,pleasephotocopythispageandencloseitwiththisform.

Detailsofjudgmentorcivilpenalty1

Dateofjudgmentorcivilpenalty D D M M Y Y Y Y

Countrywherejudgmentmade


Detailsofjudgmentorcivilpenalty2

Dateofjudgmentorcivilpenalty D D M M Y Y Y Y

Countrywherejudgmentmade

YoumustanswerthefollowingquestionsevenifyouhaveansweredthatyouhavenotbeenconvictedofanycriminaloffenceintheUKoranyothercountry.

Forhelpinansweringthesequestions,pleaseseethedefinitionsattheendofthissection.

Providemoredetailsonaseparatesheetofpaperifnecessaryandsubmititwithyourapplication.

7.3 Haveyoueverbeenchargedorindictedinanycountrywithacriminaloffenceforwhichyouhavenotyetbeentriedincourt?

Yes Please provide details: No gotoquestion7.4

7.4 Ineitherpeaceorwartime,haveyoueverbeeninvolvedin,orbeensuspectedofinvolvementin,warcrimes,crimesagainsthumanityorgenocide?


7.5 Haveyoueverbeeninvolvedin,supportedorencouragedterroristactivitiesinanycountry?


7.6 Haveyoueverbeenamemberof,orgivensupportto,anorganisationwhichhasbeenassociated with terrorism.



7.7 Haveyouever,byanymeansormedium,expressedviewsthatjustifyorglorifyterroristviolenceorthatmayencourageotherstoterroristactsorotherseriouscriminalacts?


7.8 Haveyoueverengagedinanyotheractivitieswhichmightindicatethatyoumaynotbeconsideredtobeapersonofgoodcharacter?

Yes Please provide details: No

DefinitionsThefollowinginformationprovidesguidanceonactionswhichmayconstitutewarcrimes,crimesagainsthumanity,genocide,orterroristactivities.

Thisguidanceisnotexhaustive.Thefulldefinitionsofwarcrimes,crimesagainsthumanityandgenocidecanbefoundinSchedule8oftheInternationalCriminalCourtAct2001atwww. legislation.gov.uk/ukpga/2001/17orpurchasedfromTheStationeryOffice(telephone08706005522).Itistheyourresponsibilitytosatisfyyourselfthatyouarefamiliarwiththedefinitionsandcan answer the questions accurately.

War crimesGravebreachesoftheGenevaConventionscommittedduringanarmedconflict.Thisincludesaninternalarmedconflictandaninternationalarmedconflict.Thetypesofactsthatmayconstituteawarcrimeincludewilfulkilling,torture,extensivedestructionofpropertynotjustifiedbymilitarynecessity,unlawfuldeportation,theintentionaltargetingofciviliansandthetakingofhostages.

Crimes against humanityActscommittedatanytime(notjustduringarmedconflict)aspartofawidespreadorsystematicattack,directedagainstanycivilianpopulationwithknowledgeoftheattack.Thiswouldincludeoffencessuchasmurder,torture,rape,severedeprivationoflibertyinviolationoffundamentalrules of international law and enforced disappearance of persons.

GenocideActscommittedwithintenttodestroy,inwholeorinpart,anational,ethnical,racialorreligiousgroup.

http://www.legislation.gov.uk/ukpga/2001/17

http://www.legislation.gov.uk/ukpga/2001/17


Terrorist activitiesAnyactcommitted,orthethreatofaction,designedtoinfluenceagovernmentorintimidatethepublicandmadeforthepurposesofadvancingapolitical,religiousorideologicalcauseand that involves serious violence against a person; that may endanger another person’s life; createsaseriousrisktothehealthorsafetyofthepublic;involvesseriousdamagetoproperty;is designed to seriously disrupt or interfere with an electronic system.

Organisations concerned with terrorismAn organisation is concerned with terrorism if it commits or participates in acts of terrorism; preparesforterrorism;promotesorencouragesterrorism(includingtheunlawfulglorificationofterrorism);orisotherwiseconcernedinterrorism.


Section 8 - Public funds (state benefits)Thissectionasksforinformationaboutanypublicfundsorstatebenefits(alsoknownas‘socialassistance’)youareclaiming,orhaveclaimed,orthatyoursponsorisclaiming,orhasclaimed,sinceyouhavelivedintheUK.

Note:youonlyhavetocompletethissectionifyou’reapplyingastheprimarycarerofachild

8.1 Areyouclaiming,orhaveyou/hasyoursponsorclaimed,sincelivingintheUK,anyofthepublicfundsorstatebenefitslistedinthetablebelow?

Yes No

8.2 Ifyouhaveansweredyes,pleasecompletethetablebelowtoshowtheamountyou/yoursponsorreceive(s),orreceived,eachweek/monthandforhowlongthebenefithasbeenpaid.

Benefit Who receives it Amount you/they receive

each week/month – please specify

frequency

Date you/they

started receiving

this benefit

Date you/they

stopped receiving

this benefit (if you no

longer receive it)

Attendance allowance

Carer’s allowance

Childbenefit

Childtaxcredit

Counciltaxbenefit

Counciltaxreduction


Disabilitylivingallowance

Employment and support allowance–income-related(work-relatedactivitygroup)Employment and support allowance–income-related(supportgroup)

Employment and support allowance–contribution-based(work-relatedactivitygroup)Employment and support allowance–contribution-based(supportgroup)

Housingbenefit

Homelessness and housing assistance

Incomesupport

Jobseeker’sallowance–income-based

Jobseeker’sallowance–contribution-based

Personal independence payment

Severedisablementallowance


Social Fund payment

State pension credit

Workingtaxcredit

Universal credit

8.3 Ifthereareanybenefitsyouhaveclaimednotinthelistabove,orifyouwishtoprovideanyotherinformation,pleaseusetheboxbelow.

Nowgotosection9.


Section 9 - Documents and evidenceYoumustsubmitproofofyouridentityandnationalityandproofthatyouhaveaderivativerightofresidence.Ifyoudonot,yourapplicationwillbeinvalidandwillbereturnedtoyou.

Thissectionprovidesguidanceonwhatdocumentstosubmit.

Unlessotherwisestated,pleasesendoriginaldocumentsonly.Photocopiesarenotacceptable.Ifyou’reunabletosendtheoriginal,pleaseexplainwhy.Weareunlikelytobeabletoapproveyour application without sight of the original document.

Pleasealsosubmitphotocopiesofalldocumentssubmittedaswellastheoriginaldocuments.

Ifyoureceivebankstatementsinonline/electronicformatonly,askyourbanktostampeachpagewiththeirofficialstamp.

IfyouwishtosendanydocumentswhicharenotinEnglishorWelsh,youmustgetthedocumenttranslatedbyaqualifiedprofessionaltranslator.Askthetranslatorortranslationcompanytoconfirminwritingonthetranslation:

• that it’s a ‘true and accurate translation of the original document’

• the date of the translation

• the full name and contact details of the translator or a representative of the translation company

Pleaseticktherelevantboxesbelowtoshowwhatdocuments(and,whererelevant,howmanyofeach)you’resubmitting.Ifyou’resubmittinganydocumentsnotlistedintherelevantsection,please list them at under ‘other evidence’ at the end of this section.

1 – Your personal details

All applicants should complete this section

How many?

PhotographsTwopassportsizedphotographswithyournamewrittenonthebackandwhich conform to the standards on www.gov.uk/photos-for-passports

Proof of your identityYourvalidpassport,or

Your valid EEA national identity card

Makesurethatyouhavesignedyourpassport.

Youmustprovidetherelevantidentitydocuments.Ifyou’renotabletosubmitavalidpassportorEEAnationalidentitycardduetocircumstancesbeyondyourcontrol,youmustexplainwhynotandsubmitanyalternativeevidenceofyouridentityandnationality(seealsosection1.16).Alternativeevidencesubmitted:



2 – Primary carersPlease complete this section if you have completed sections 2, 3 or 5 of this form as a primary carer. If you have completed section 6 of this form as the dependent child of a primary carer, you should also complete this section for your primary carer.

How many?

Evidence of identity and nationality of the person for whom you are a primary carer

Theirvalidpassport,or

TheirvalidEEAnationalidentitycard

Youmustprovidetherelevantidentitydocuments.Ifyou’renotabletosubmitavalidpassportorEEAnationalidentitycardforthepersonforwhomyouaretheprimarycarerduetocircumstancesbeyondyourcontrol,youmustexplainwhynotandsubmitanyalternativeevidenceofyouridentityandnationality(seealsosection1.16).Alternativeevidencesubmitted:

Photographs

Apassportsizedphotographwiththeirnamewrittenonthebackandwhichconforms to the standards on www.gov.uk/photos-for-passports

Evidence of relationship to the person for whom you are the primary carerBirthcertificate(s)

Adoptioncertificate(s)

Court order detailing legal guardianship

Marriagecertificate

Civilpartnershipcertificate

Evidence of caring responsibilitiesResidence or custody order

NHSletters

School letters

Social services letters

Other(pleasegivedetails)



3 – Primary carer of a British citizen (‘Zambrano’ cases)

Please complete this section if you have completed section 2 of this form

If you have completed section 6 if this form as the dependent child of a primary carer of a British citizen, you should also complete this section for your primary carer.

How many?

Evidence that the person for whom you are the primary carer is a British citizen

ValidBritishpassport

CertificateofregistrationasaBritishcitizenissuedbytheHomeOffice

NationalitystatusletterissuedbytheHomeOfficeconfirmingBritishcitizenstatusCertificateofnaturalisationasaBritishcitizenissuedbytheHomeOffice

CertificateofentitlementtoarightofabodeintheUnitedKingdomissuedundersection2(1)(a)oftheImmigrationAct1971UKbirthcertificateshowingbirthintheUKbefore1January1983

UKbirthcertificateshowingbirthintheUKonorafter1January1983andevidencethateitherparentwaseitheraBritishcitizenorsettledintheUKatthetimeofthebirth.

4 – Primary carer of a self-sufficient EEA national child (‘Chen’ cases)

Please complete this section if you have completed section 3 of this form

If you have completed section 6 if this form as the dependent child of a primary carer of a self-sufficient EEA national child, you should also complete this section for your primary carer.

How many?

Proof of financial resources available to the EEA national child

Itemisedbankstatementscoveringatleastthelastthreemonths

Buildingsocietypassbook

Evidence of receipt of a pension

Evidence of income from rental property

Wageslipsfromlawfulemployment

Evidenceofincomefromlawfulself-employment

Ifarelative,friendorotherpersonororganisationisfinanciallysupportingthechild,asignedanddatedletterfromthatpersonororganisationconfirmingthattheyaresupportingyouandforhowlong.Youmustalsosubmitevidenceoftheirfinancesasabove.


Anyotherrelevantevidenceofthefinancialresourcesavailabletoyou(pleaselist):

Photographs

Apassportsizedphotographwiththeirnamewrittenonthebackandwhichconforms to the standards on www.gov.uk/photos-for-passports

Proof of comprehensive sickness insurance for the EEA national child and their primary carer(s)

Ifthechildhasprivatemedicalinsurance,ascheduleorotherdocumentfromtheinsuranceprovideroutliningthelevelofcover.Thismustcoverthechildandtheirprimarycarer(s)forthemajorityofriskswhiletheyareintheUKValidEuropeanHealthInsuranceCard(EHIC)issuedbyanEEAMemberState(otherthantheUK),togetherwithastatementconfirmingthatyoudonotintendtolivepermanentlyintheUKForm S1

FormS2

Form S3

5 – Child of an EEA national former worker, or the primary carer of such a child (‘Ibrahim/Teixeira’ cases)

Please complete this section if you have completed section 4 or 5 of this form.

If you have completed section 6 if this form as the dependent child of a primary carer of a child who is in education in the UK, you should also complete this section for your primary carer.

How many?

Evidence of relationship between the child in education and the EEA national former worker

Birthcertificate

Adoptioncertificate

Evidence of EEA nationality of the former worker Valid EEA passport

ValidEEAnationalIDcard

RegistrationcertificateissuedbytheHomeOffice

Evidence of the EEA national’s employment



AletterfromtheEEAnational’spreviousemployerconfirmingthedatesofemployment.Thismustbesignedanddatedbytheemployer,includetheemployer’scontactdetails,andbeontheletter-headedpaperoftheemployer. Wageslips,and/or

Yourbankstatementsshowingreceiptofyourwages

Signed and dated contract of employment

FormP45

MostrecentP60

Letterofredundancyordismissalfromtheemployer

Letterfromtheemployeracceptingyourresignation

Employmenttribunaljudgment

Anyotherevidence(pleaselist):

TheevidencesubmittedshoulddemonstratethattheEEAnationalwasaworkeratatimewhenthechildwasresidingintheUK.

Evidence of the EEA national’s residence in the UK

Tenancyagreement(s)

Mortgageagreements(s)

Bankstatement(s)

Utilitybills

NHSletters


TheevidencesubmittedshoulddemonstratethattheEEAnationalwasresidentintheUKatatimewhenthechildwasineducationintheUK.

Evidence of the child’s residence in the UKSchool letters

NHSletters


Residence/custodyorders

Anyotherevidence(pleaselist)

TheevidencesubmittedshoulddemonstratethatthechildwasresidingintheUKatatimewhentheEEAnationalwasaworker.

Evidence that the child is in education in the UKSchoolletters/reports

LocalEducationAuthorityletters


TheevidenceshoulddemonstratethatthechildwasineducationintheUKatatimewhentheEEAnationalformerworkerwasresidingintheUK,andthatthechildiscurrentlyineducationintheUK

6 – Dependent child of a primary carer with a derivative right of residence

Please complete the following section if you have completed section 6 of this form.

How many?

Evidence of your relationship to your primary carer

Birthcertificate(s)

Adoptioncertificate(s)

Court order detailing legal guardianship

Evidence of identity of your primary carerValid passport

ValidEEAnationalIDcard

Youmustprovidetherelevantidentitydocuments.Ifyou’renotabletosubmitavalidpassportorEEAnationalidentitycardforyourprimarycarerduetocircumstancesbeyondyourcontrol,youmustexplainwhynotandsubmitanyalternativeevidenceofyouridentityandnationality(seealsosection1.16).Alternativeevidencesubmitted:


Evidence of your primary carer’s caring responsibilities for youResidence/custodyorder

NHSletters

School letters

Social services letters

Anyotherevidence(pleasegivedetails):

Other relevant evidence not listed above How many?

Ifyouhavesubmittedanyotherdocumentswithyourapplicationnotlistedabove,pleaselistthembelow:

Nowgotosection10(declaration).


Section 10 - DeclarationPleasereadthedeclarationbelowandsignit.Itshouldbesignedbyyou(theapplicant)andnotbyarepresentativeorotherpersonactingonyourbehalf.Ifyouareunder18,yourparentorguardian may sign it.

Ifthedeclarationisnotcompleted,wemayrejectyourapplication.

Iherebyapplyforaderivativeresidencecard.TheinformationIhavegiveninthisformiscompleteandistruetothebestofmyknowledge.

Iconfirmthatthephotographssubmittedwiththisformareatruelikenessofme,asnamedonthebackofeachphotograph,andthatIhavehadtheopportunitytoseetheHomeOfficephotograph guidance.

Iconfirmthatif,beforethisapplicationisdecided,thereisamaterialchangeinmycircumstancesornewinformationrelevanttothisapplicationbecomesavailable,IwillinformtheHomeOffice.

IunderstandthatallinformationprovidedbymetotheHomeOfficewillbetreatedinconfidencebutthatitmaybedisclosedtoothergovernmentdepartments,agencies,localauthorities,thepolice,foreigngovernmentsandotherbodiesforimmigrationpurposesortoenablethemtoperformtheirfunctions,andthat,ifsuchbodiesprovidetheHomeOfficewithanyinformationaboutmewhichmayberelevantforimmigrationpurposes,itmaybeusedinreachingadecisiononmyapplicationoronwhetherIhavearighttoresideintheUK.

Iunderstandthatmydetailsmayincertaincircumstancesbepassedtofraudpreventionagenciestopreventanddetectfraudandmoneylaundering.IalsounderstandthatsuchagenciesmayprovidetheHomeOfficewithinformationaboutme.FurtherdetailsexplainingwheninformationmaybepassedtoorfromfraudpreventionagenciesandhowthatinformationmaybeusedcanbeobtainedfromtheHomeOfficewebsite.

Iunderstandthatdocumentsprovidedinsupportofthisapplicationwillbecheckedforauthenticity,andthatfalsedocumentswillberetainedandmayresultinmyapplicationbeingrefusedandinmyprosecutionandsubsequentremovalfromtheUK.

IunderstandthattheHomeOfficemayalsousetheinformationprovidedbymefortrainingpurposes.

IamawarethatitisanoffencetomakeastatementorrepresentationwhichIknowtobefalseordonotbelievetobetrue,ortoobtain,orseektoobtainaregistrationcertificatebymeanswhich include deception.

IunderstandthatifIaminformingtheHomeOfficethatIhavechangedmygender,thesedetailsmayincertaincircumstancesbesharedwithotherpartsoftheHomeOffice.Iconsenttothis,wherenecessary,andunderstandthatthisinformationwillonlybesharedinlimitedcircumstancesrelatingtoidentityandsecurityinlinewithsection22oftheGenderRecognitionAct.IamawaretheywillotherwisebetreatedinconfidenceandthatmyrightsundertheEqualityAct2010,DataProtectionAct1998andArticle8oftheEuropeanConventiononHumanRightswillbeunaffected.

Signed Date D D M M Y Y Y Y


Identity document checklistPleasecompletethetablebelowtohelpuscheckthatwehavereceivedyouridentitydocumentsandtokeeparecordofthemwhiletheyarewithus.

Documents Howmany?

Passports

Nationalidentitycards

Biometricresidencepermits(BRPs)

Birthcertificates

Marriage/civilpartnershipcertificates

Drivinglicence(paperorphoto)

Deed poll

Pleasemakesureyousendyourapplicationtothecorrectaddressasshownonthefrontofthisform. Sending it to any other address will delay your application.