DRF1 Derivative Residence Card - gov.uk · 2019-03-14 · Derivative Residence Card (DRF1) - Version 03/2019 Page 2 of 74 The fee There is a fee of £65 for each person applying for

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:

• the primary carer of a British citizen child or dependent adult (‘Zambrano’)

• theprimarycarerofaself-sufficientEEAnationalchild(‘Chen’)

• the child of an EEA national former worker where the child is in education in the UK (‘Ibr ahim/Teixeira’)

• the primary carer of a child of an EEA national former worker where the child is in education in the UK (‘Ibrahim/Teixeira’)

• the dependent child aged under 18 of a primary carer in one of the categories above

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.

Version 03/2019

This form is to be used for applications made on or after 14 March 2019

The Home Office will use the personal information you provide to consider your application. We may also share your information with other public and private sector organisations in the UK and overseas. For more detail please see the Privacy Notice for the Border, Immigration and Citizenship system at www.gov.uk/government/publications/personal-information-use-in-borders-immigration-and-citizenship. This also sets out your rights under the Data Protection Act 2018 and explains how you can access your personal information and complain if you have concerns about how we are using it.

Derivative Residence Card (DRF1) - Version 03/2019 Page 2 of 74

The fee

There is a fee of £65 for each person applying for a derivative residence card. If you do not pay the fee, your application will be invalid and returned to you without consideration. See the payment guidance notes, enclosed with this application form, for further information.

Each person claiming a derivative right of residence must complete their own application form and pay the specified fee.

Biometric information for non-EEA nationals

If you are a non-EEA national applying for a derivative residence card, you must give your biometric information (fingerprints and a digital photograph) before your application will be considered. If you do not, we may reject your application.

See pages 7-12 of this form for further information.

Completing the application form

Complete all relevant sections of the form as directed. Use a black pen and write names, addresses and similar details in capital letters. In sections where you are asked to give your personal details and address, leave a space between each name and each part of the address.

You must also send the relevant evidence as specified in section 9 of this form.

Only complete the sections of the form that are relevant to you. If a section does not apply to you, leave it blank.

If there is insufficient space in any section of the application form, please continue on a separate sheet.

To save paper, postage and storage costs, we recommend that you only print and send us the:

• front page of the form, and

• sections of the form that you have actually completed (including the payment section and, if required, the biometric section).

Where to send your completed application

You must send the completed application form, supporting documents, and payment of £65 to the address below:

Department 600

UKVI

The Capital

Old Hall Street

Liverpool

L3 9PP

Sending it to any other address may delay your application.


Payment Guidance

The FeeThere is a fee of £65 for this application.

Please note that your application will be rejected as invalid if you do not pay the specified fee.

How you can payYou can pay by any of the following methods:

• Cheque/Bankers Draft• Postal Order • Credit card - Mastercard, Visa (including Electron) or American Express (Amex)• Debit card - Delta, Maestro* (including Solo)

* Maestro - We can accept only Maestro cards issued in the UK.

Please note that when making large or multiple payments using your credit card, the anti-fraud measures that banks operate sometimes stop the full payment being taken. This can happen for a number of reasons. To prevent this you may wish to inform your bank of your intention to make large or multiple payments in advance so that your bank allows the full payment to be taken when you submit your application. Please be aware that not all banks offer this service.

Cheques and postal ordersYou must make the cheque or postal order payable to ‘Home Office’ and cross the cheque or postal order A/C Payee only. Please write the full name and date of birth of the applicant on the back of the cheque and/or each postal order and keep the postal order receipt(s). Please make sure that the date and the amount (words and figures) are correct and that the cheque is signed properly. Attach your cheque or postal order(s) to the front of the application form.

Completing the payment details pageTo ensure that your payment is processed without any delay, please follow this guidance when completing the Payment Details section.

1-2 The address at 1 should be the contact address in the UK for any correspondence. If it is not your home address (eg a solicitor or other authorised immigration adviser may be submitting the application), give the contact name at 2.

3 This should be the full name of the main applicant as given in his or her passport or travel document.

4 Date of birth - for example, 3 January 1980 should be written 03 01 1980 in the spaces provided.

5 If you do not select a fee then we cannot take a payment and your application will be rejected as invalid.


9 The name as displayed on the credit/debit card

10 Card number - this is the long number across the centre of the card

11 The card security number is a three-digit security code known as the card verification value (CVV). It consists of the last three numbers on the signature strip on the back of the card as shown below. For Amex the security code consists of 4 digits and is found on the front of the card.

If you do not provide the CVV number, we cannot take the payment and your application will be rejected as invalid.

12 Cardholder’s signature - the person named on the credit/debit card must sign and date these sections.

4567 123AUTHORISED SIGNATURE

CVV123

AMERICAN EXPRESS

1234 1234 123456 12345

CVV 1234


Making sure your application is validTo make a valid application, you must:

• apply online, or with this version of form EEA(DRF1), unless there are circumstances beyond your control;

• pay the specified fee by one of the methods set out in the Payment Guidance section;

• provide photographs of yourself, your partner and any children under 18 who are applying with you as specified in the application form;

• provide a valid passport, national identity card or travel document, as required;

• provide the necessary evidence or proof to support your application, as required (see Section 9 for further information); and

• complete the following sections of the form: ▪ Payment details ▪ Section 1 - Applicant’s details ▪ Section 10 - Declaration(s)

and, where relevant: ▪ Biometric information for non-EEA nationals ▪ Section 1(C) - Family members included in your application form

For non-EEA national applicants, and any non-EEA national family members included in the application, you must enrol your biometric data in compliance with the biometric enrollment letter that we will send you after we have received your application.

If your application is rejected as invalidIf you fail to do any of these things, for example, if the payment submitted does not cover the full cost of your application, or fails to meet the requirements set out above, your application will be rejected as invalid.

The fee charged is for the processing and consideration of the application. This fee will be payable once the application form is received by the Home Office or its payment processing agent, regardless of the outcome of the application.

We cannot begin the consideration process until the payment has cleared. We allow 5 working days for payments made by cheque to clear, credit/debit cards and postal orders will clear immediately.

If your application is rejected as invalid your application will not be considered and your fee will be refunded less an administration fee of £25 for each person included in the application. We will return the form with any documentation submitted to you. As this is not a decision on whether you qualify for the documentation you have applied for, you will be able to make a new application, correcting any errors or omissions, and paying the correct fee.


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Payment details - DRF1Please complete this page in block capitals and black ink after first reading the payment guidance. It is mandatory to complete this section. If it is not complete, the application will be invalid and will be returned to you.

1. Contact address in the UK for correspondence

Postcode

2. Contact name in the UK if different from that of the applicant

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

4. Date of Birth D D M M Y Y Y Y

5. Amount - please tick the amount you are paying. If no fee is ticked we cannot take a payment and your application will be rejected as invalid.

Amount to pay - single applicant - £65

6. How are you paying? Please tick a box.

Postal order Cheque Debit or credit card Banker’s draft

7. Paying by cheque/bankers draft - please give cheque details below (payable to ‘Home Office’)Cheque number Account number Sort code

- -

8. Which card are you using for payment? Please tick a box

Visa/Electron Mastercard/Amex Maestro/Solo Delta

9. Name on card

10. Card number

Valid from Expiry date CVV number Issue No. if11. Card details / / available

12. Cardholders signature Date


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Biometric information for non-EEA nationals: form DRF1Note: this section applies to non-EEA nationals applying for a derivative residence card only. Do not complete this section if you are an EEA national applying for a derivative residence card – proceed straight to section 1 instead.

If you are a non-EEA national applying for a derivative residence card, you must complete this section in full. If you do not, we may reject your application and return it to you without consideration.

Introduction

In accordance with the Immigration (Provision of Physical Data) Regulations 2006 (as amended), any non-EEA national applying for a derivative residence card as evidence of their right to reside under the Immigration (European Economic Area) Regulations 2016 (‘the EEA Regulations’) must give their biometric information (fingerprints and a digital photograph) before their application will be considered. You must complete this section fully to ensure that we have the correct information when you attend your biometric appointment.

When we receive your application, we will send you a biometric enrolment letter. This will instruct you to make an appointment at a designated Post Office to have your biometric information recorded. You will be charged an additional handling fee for this service, payable to the Post Office Ltd. You must pay the fee by cash or debit card when you attend your biometric enrolment appointment.

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

Your application may be rejected as invalid if you do not enrol your biometric information when requested. For more information about biometrics, please visit www.gov.uk/biometric-residence-permits

Definitions

In this section, the term ‘residence card (biometric format)’ means a residence card, permanent residence card or derivative residence card issued under the EEA Regulations after you have given your biometric information. This is issued as a separate biometric card and not as a vignette or sticker in your passport, travel document, or other document.

If you currently have, or last had:

• a residence card (biometric format) confirming your right to reside under the EEA Regulations, or

• a biometric residence permit confirming that you had been granted leave to remain under the Immigration Rules or Immigration Act 1971,

you must include this document with your application (unless you have already returned the document to us).


Your personal details

1. Your title - please tick(Please state)

Mr Mrs Miss Ms Master Other

Your full name:

Your nationality:

Your date of birth: D D M M Y Y Y Y

Village, town or city of birth:

Country of birth:

Your home address in the UK:

Postcode

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

2. Have you been issued with a residence card (biometric format) or biometric residence permit (BRP) in connection with a previous application under the EEA Regulations or for leave to remain?

Yes go to question 3 No go to question 13

Note: if you were last issued with a residence card under the EEA Regulations in the form a vignette or sticker in your passport, travel document, or other document (such as an ‘immigration status document’), answer ‘no’ to the above question.


If yes, please give details of your residence card (biometric format) or BRP below. You must include this document with your application, unless it is not available for one of the reasons specified below.3. Residence card (biometric format) or BRP number:

4. Issue date: D D M M Y Y Y Y

5. Expiry date: D D M M Y Y Y Y

6. Nationality recorded on the residence card (biometric format) or BRP:

7. Place of issue:

8. Residence card (biometric format) or BRP enclosed?

Yes No

If not enclosed then please state where the residence card (biometric format) or BRP is now:

Returned to Home Office - go to question 9

Stolen - go to question 10

Lost - go to question 11

Other - go to question 12

9. If the residence card (biometric format) or BRP has been returned to the Home Office, please give details below.

Reason it was returned:

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

10. If the residence card (biometric format) or BRP was stolen, please give details below.

Police report number:


Crime reference number:

Police station:

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

Date reported to the Home Office card management service:D D M M Y Y Y Y

11. If the residence card (biometric format) or BRP was lost, please give details below.

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

Where it was lost:

Date reported to the Home Office card management service:D D M M Y Y Y Y

12. If the residence card (biometric format) or BRP is not enclosed for any other reason, please explain why you are unable to provide it below:

Fingerprints in previous immigration applications13. Have you had your fingerprints taken as part of a previous UK immigration application made

in the UK or abroad (including for an EEA family permit)?Yes continue below No go to question 14

Please give details below for each case. If you need more space, continue on a separate sheet and enclose it with this application form.The name in which your fingerprints were taken

Date on which they were taken (DD/MM/YYYY)

Place at which they were taken

British diplomatic post if they were taken abroad


Special arrangements for medical conditions

14. Do you have a medical or physical condition which may require special arrangements for your biometric features to be recorded?

Yes Please provide us with a letter from a treating clinician registered with the General Medical Council (GMC) giving details of the condition and/or special needs and explaining any arrangements that may be necessary.

No

Applicants under the age of 16

15. Are you under the age of 16? Yes answer questions

16 to 18No go to question 19

16. Any child under the age of 16 must be accompanied by a responsible adult when they attend their biometric appointment. Please give details of the person who will be accompanying you when you attend your biometric appointment.

Name of responsible adult:

Date of birth of responsible adult: D D M M Y Y Y Y

Nationality of responsible adult:

Relationship of responsible adult to you:

17. Is the responsible adult your parent or legal guardian?

Yes go to question 19 No go to question 18

Note: The responsible adult accompanying any child under the age of 16 will need to provide a form of photographic identification, such as a passport or UK photo driving licence. If that person is not the parent or guardian of the child, they must have a letter confirming that they are a responsible adult who has a close connection to the child and has been authorised to accompany him or her.


18. Please explain why your parent or legal guardian will not be accompanying you to the ap-pointment:

Declaration

19. As required by the Immigration (Provision of Physical Data) Regulations 2006 (as amended), I confirm that I am applying for a residence card (biometric format) for myself. If I am a sole applicant under the age of 16, I understand that the Home Office may make enquiries about any responsible adult nominated to be present when my fingerprints and/or a photograph are taken.

Signed Date D D M M Y Y Y Y

Now go to section 1.


Section 1 - Applicant’s detailsYou must complete this section as required, even if you have already completed the biometric section. If you do not, your application will be invalid and will be returned to you.

A. Category of application1.1 Which category are you applying for a derivative residence card under? Please tick:

Primary carer of a British citizen child or dependent adult (‘Zambrano’)

Primary carer of an EEA national child who is exercising their Treaty rights as a self-sufficient person (‘Chen’)

Child of an EEA national worker or former worker where the child is in education in the UK (‘Ibrahim and Texeira’)

Primary carer of a child of an EEA national worker or former worker where the child is in education in the UK (‘Ibrahim and Teixeira’)

Dependent child aged under 18 of a primary carer in one of the categories above.

B. Your personal details

Photographs - You must provide two recent identical photographs of yourself with your full name on the back of each one. Please place the photographs in a small sealed envelope and attach it with a staple or paper clip at the right-hand side.

Please make sure that the staple or paper clip does not damage or mark the photographs.

All photographs must be as specified in the photograph guidance. A copy of the photograph guidance can be found at: www.gov.uk/photos-for-passports

Your name1.2 Your title - please tick

(Please state)Mr Mrs Miss Ms Master Other

1.3 Your full name as shown in your passport, travel document or EEA national identity card

1.4 Surname or family name as shown in your passport, travel document or EEA national identity card


1.5 Any other name(s) by which you are or have been knownName(s) Dates during which you have

used this/these name(s)

1.6 If you have changed your name, why did you change it?

Marriage/civil partnership Divorce

Other (please state)

Your gender and relationship status

1.7 What is your gender? Male Female

1.8 What is your relationship status?

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 Your date of birth D D M M Y Y Y Y

1.10 Village, town or city of birth

1.11 Country of birth

1.12 Your current nationality (as stated in your passport, travel document or national identity card if you are an EEA national)


1.13 Do you currently hold, or have you ever held, any other nationality or citizenship?

Yes No

1.14 If Yes, please give details below:Nationality or citizenship Dates held

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

* If you still hold the relevant nationality or citizenship, please write ‘present’.

Your passport or national identity card

1.15 Please give details of your current passport, travel document or (if you are an EEA national) national identity card in the table below.

Passport or travel document

National identity card (EEA national only)

Document reference number

Place of issue

Issuing authority

Date of issue

Expiry date

1.16 Are you submitting a valid passport, travel document or (if you are an EEA national) national identity card with this application?

Yes, valid passport Yes, valid travel document

Yes, valid national identity card No

1.17 If you have answered no to question 1.16, please say why not in the box below and submit any relevant supporting evidence

Reason(s) for not submitting a valid passport, travel document or national identity card:


Unless your valid passport, travel document or national identity card is already with the Home Office, you must also submit alternative evidence of your identity and nationality. Please say what this evidence is in the box below

Please note: we will only accept alternative evidence of your identity and nationality if you can show that you are not able to submit a valid passport, travel document or national identity card due to circumstances beyond your control.

Your personal reference numbers

1.18 Home Office reference number(s):

1.19 UK national insurance number:

1.20 Biometric residence permit number:

1.21 Residence card number:

1.22 Any other Home Office reference number:

If you do not have any of the above reference numbers, please write ‘N/A’ (not applicable) in the relevant box or leave it blank.

Your contact details

1.23 Your home address in the UK:

Postcode

1.24 Your name and address in the UK for all correspondence if different from your home address:

Postcode


1.25 Is the address in 1.24 the address of your representative or authorised immigration adviser?

Yes No Not applicable

1.26 Your home/daytime telephone number 1.27 Your mobile number if you have one

1.28 Your email address and that of your representative if you have one. Please write your email address clearly in block capitals and note that we can only send updates to the email address you provide.

Your email address:

Please re-enter your email address in block capitals:

Your representative’s email address:

The Home Office or persons acting on behalf of the Home Office may use the above email address(es) to communicate with you about your application. You must check your email account at regular intervals and respond to any further information requests as soon as possible.


C. Family members applying with youIf you have any family members or relatives applying for a derivative residence card at the same time as you, please enter their details below. This will help us keep your applications together. Continue on a separate sheet if necessary.

Please note that each person applying for a derivative residence card must complete their own application form and pay the specified application fee.

We strongly recommend that you enclose all applications in the same envelope if you want them to be considered together.

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

Document applied for



Section 2 - Primary carer of a British citizen child or dependent adult (‘Zambrano’)You must also complete sections 7 - 10

2.1 Please tick one of the following boxes to confirm whether the British citizen of whom you are the primary carer is:

a British citizen child aged under 18

a dependent British citizen adult aged 18 or over

2.2 Please tick one of the following boxes to confirm whether you are applying as:

the sole primary carer of a British citizen

a joint primary carer who shares caring responsibility for a British citizen equally with another person

A. The British citizen’s personal detailsPhotographsEnclose a passport-sized photograph of the British citizen for whom you are the primary carer with their full name written clearly on the back.

Please place the photograph in a small sealed envelope and attach it with a staple or paper clip at the right-hand side.

Please make sure that the staple or paper clip does not damage or mark the photograph.


British citizen’s name2.3 Title - please tick


2.4 Full name as shown in their passport

2.5 Surname or family name as shown in their passport


2.6 Any other name(s) they are or have been, known by

Name(s) Dates during which they have used this/these name(s)

2.7 If they have changed their name, why did they change it?



British citizen’s gender and relationship status

2.8 What is their gender? Male Female

2.9 What is their relationship status?Married Dissolved civil partnership



Divorced Separated



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




2.12 Do they hold British citizenship?

Yes No

2.13 Evidence of British citizenship submitted:

current British citizen passport

passport number:

certificate of registration as a British citizen issued by the Home Office

nationality status letter issued by the Home Office confirming British citizen status

certificate of naturalisation as a British citizen issued by the Home Office

certificate of entitlement to a right of abode in the United Kingdom issued under section 2(1)(a) of the Immigration Act 1971

UK birth certificate showing birth in the UK before 1 January 1983

UK birth certificate showing birth in the UK on or after 1 January 1983 and evidence that either parent was either a British citizen or settled in the UK at the time of the birth.

Please note: Birth in the UK on or after 1 January 1983 does not automatically confer British citizenship. As stated above, you must also show that either parent was either a British citizen or settled in the UK at the time of the birth.

2.14 Date of birth D D M M Y Y Y Y

2.15 Do they currently hold, or have they ever held, any other nationality or citizenship?

Yes No




* If they still hold the relevant nationality or citizenship, please write ‘present’.

British citizen’s contact details

2.17 Please give the British citizen’s home address in the UK, if different from the address given in section 1.

Postcode

B. Your relationship to the British citizen2.18 Please tick one of the following boxes to indicate your relationship to the British citizen of whom you are the primary carer:

parent

legal guardian

grandparent

spouse or civil partner

child

grandchild

sibling

Please note – if you are not in one of the categories set out above, you will not qualify for a right of residence as the primary carer of a British citizen.

Please see section 9 for information on evidence that can be submitted to demonstrate your relationship to the British citizen.


C. Dependency

2.19 Please give details about how the British citizen is wholly reliant on you (or you and your joint primary carer) for their care (for example, financial dependence, personal care):

2.20 Is there another person in the UK who could or does assume caring responsibility for the British citizen?

Yes - give details No

2.21 Please give details of any other relatives of the British citizen who are living in the UK:Full name Date of birth Nationality Relationship to the British

citizen


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

If you are applying as the primary carer of the British citizen aged under 18, and you are not their parent, please complete this section for both parents of the British citizen.

If you are the British citizen’s parent, and the child’s other parent is not applying for a derivative residence card (and has not already been issued with a derivative residence card), please complete this section for the other parent.

Mother Father2.22 Full name

2.23 Date of birth2.24 Nationality2.25 Immigration status

2.26 Current address (or last know address)

2.27 What sort of contact (including face to face, by telephone or any other means) does the child have with this parent?2.28 How often does this contact take place? (For example, once a week, twice a month)2.29 When was the last known contact between the child and this parent?2.30 Is there a formal Court order in place for the child (for example, a custody agreement, residence order or contact order)? If so, please provide a copy of this agreement/order.2.31 Does this parent provide any financial support or maintenance payments for the child?2.32 If you have answered yes to question 2.31, please list these payments and the amount received per month


Primary carer of dependent British adult aged 18 or over

If you are the primary carer of a dependent British citizen aged 18 or over, please complete the following section.

2.33 What is the nature of the care that you provide to the British citizen?

2.34 How many hours of care do you provide for the British citizen each week?

2.35 What date did you start providing this care? D D M M Y Y Y Y

2.36 Who was providing care to the British citizen before this date?

2.37 Please explain why the previous care arrangements could not continue

2.38 Does the British citizen currently receive care from anybody else (for example, another person, the local authority or a private care provider?)

Yes No

2.39 If you have answered yes to question 2.38 above, please give details of who provides this care, what care is provided, and for how many hours each week?

2.40 If you have answered no to question 2.38 above, please give details of what enquiries have been made as to whether such care can be provided?


D. Other primary carer

If there is another person in the UK who:

• is applying for a derivative residence card as the primary carer of the British citizen at the same time as you,

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

• has been issued with a derivative residence card as the primary carer of the British citizen, or

• is relying on a derivative right of residence in the UK on the basis that they are the primary carer of the British citizen;

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

2.41 Their title - please tick(Please state)


2.42 Their name as in their passport (or national ID card if they are an EEA national)

2.43 Their surname as in their passport (or national ID card if they are an EEA national)

2.44 Any other name(s) by which they are or have ever been known.Name(s) Dates during which they have


2.45 Their date of birth D D M M Y Y Y Y


2.47 What is their nationality?


2.48 Their place of birth – town or city and country

2.49 Their passport or travel document number

2.50 Their immigration status (if applicable)

2.51 Their Home Office reference (if applicable)

2.52 Their United Kingdom address

Postcode

2.53 Their relationship to the British citizen:

2.54 Their relationship to you:

2.55 Are they also applying for a derivative residence card?

Yes No

Please note that if the other primary carer wishes to apply for a derivative residence card, they must complete their own application form and pay the specified application fee.

We strongly recommend that you enclose all applications in the same envelope, and include details 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’)

If you are applying as the primary carer of an EEA national child under the age of 18 who is exercising Treaty rights in the UK as a self-sufficient person please complete this section in full. If you do not, your application may be delayed or refused.

You must also complete sections 7 - 10


the sole primary carer of a self-sufficient EEA national child

a joint primary carer who shares caring responsibility for a self-sufficient EEA national child equally with another person

A. The EEA national child’s personal detailsPhotograph(s)Enclose a passport-sized photograph of the EEA national child for whom you are the primary carer with their full name written clearly on the back.




EEA national child’s name3.2 Title - please tick


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


3.5 Any other name(s) they are or have been, known by





EEA national child’s gender and relationship status


3.8 What is their relationship status?




Divorced Separated



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



3.11 Nationality


3.12 Evidence of EEA nationality submitted:

valid passport issued by an EEA state

valid EEA national ID card

Passport or ID card number:

3.13 Do they have a registration certificate issued by the Home Office?

Yes No

3.14 If you have answered yes to question 3.13 above, please give the registration certificate number

3.15 Do they also hold British citizenship?

Yes No


Yes No



* If relevant nationality or citizenship still held, please write ‘present’.


EEA national child’s contact details

3.19 Please give the EEA national child’s home address in the UK, if different from the address given in section 1.

Postcode


B. Your relationship to the EEA national child3.20 Please tick one of the following boxes to indicate your relationship to the EEA national child of whom you are the primary carer:

parent

legal guardian

grandparent

sibling

Please note – if you are not in one of the categories set out above, you will not qualify for a right of residence as the primary carer of a self-sufficient EEA national child.

Please see section 9 for information on evidence that can be submitted to demonstrate your relationship to the EEA national child.

C. Evidence that the child is self-sufficientSufficient resourcesPlease enter the date the EEA national child started living in the UK as a self-sufficient person

D D M M Y Y Y Y

3.21 Please indicate below how the EEA national child meets the requirement to have sufficient financial resources to support themselves and their primary carer(s) without needing to claim benefits/public funds. Please provide amounts for all that apply.

Type of financial resource

Owner of financial resourceEEA national child Family member living

in the UKOther relative (not

in the UK), friend or other person

Savings

Investments

Income from rental propertyState pension

Occupational pension

Income from lawful employmentIncome from lawful self-employmentOther - please state

Please see section 9 for information on evidence that can be submitted to demonstrate the resources available to the EEA national child.


Comprehensive sickness insurance cover

3.22 Please indicate below how the EEA national child meets the requirement to have comprehensive sickness insurance for themselves (and their primary carer(s)).

Tick all that apply:

Private medical insurance

European Health Insurance Card (EHIC)* issued by an EEA Member State (not the UK)

Form S1

Form S2

Form S3

*You can only rely on an EHIC if you have not come to live permanently in the UK. As well as submitting your EHIC, you must also submit a ‘statement of intent’ confirming that you do not intend to live permanently in the UK.

Please see section 9 for information on evidence required to demonstrate comprehensive sickness insurance.

D. Dependency

3.23 Please give details about how the EEA national child is wholly reliant on you (or you and your joint primary carer) for their care (for example, financial dependence, personal care):

3.24 Is there another person in the UK who could or does assume caring responsibility for the EEA national child?



3.25 Please give details of any other relatives of the EEA national child who are living in the UK:Full name Date of birth Nationality Relationship to the British

citizen

Parent(s) of the EEA national child

If you are applying as the primary carer of the EEA national child, and you are not their parent, please complete this section for both parents of the EEA national child.

If you are the EEA national child’s parent, and the child’s other parent is not applying for a derivative residence card (and has not already been issued with a derivative residence card), please complete this section for the other parent.


3.27 Date of birth

3.28 Nationality

3.29 Immigration status

3.30 Current address (or last know address)3.31 What sort of contact (including face to face, by telephone or any other means) does the child have with this parent?3.32 How often does this contact take place? (For example, once a week, twice a month)3.33 When was the last known contact between the child and this parent?


3.34 Is there a formal Court order in place for the child (for example, a custody agreement, residence order or contact order)? If so, please provide a copy of this agreement/order.3.35 Does this parent provide any financial support or maintenance payments for the child?3.36 If you have answered yes to question 3.35, please list these 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 same time as you,

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

• has been issued with a derivative residence card as the primary carer of the EEA national child, or

• is relying on a derivative right of residence in the UK on the basis that they are the primary carer of the EEA national child;


3.37 Their title - please tick

Mr Mrs Miss Ms Master

3.38 If ‘other’, what is their title?




3.41 Any other name(s) by which they are or have ever been known.










Postcode


3.50 Their relationship to the EEA national child:

parent

legal guardian

grandparent

aunt or uncle

brother or sister

spouse or civil partner



Yes No



Section 4 - Child of an EEA national former worker where the child is in education in the UK (Ibrahim/Teixeira)If you are applying as the child of an EEA national former worker and you are in education in the UK, please complete this section in full. If you do not, your application may be delayed or refused.


If you are applying as the primary carer of a child of an EEA national former worker where that child is in education in the UK, you must complete this section and section 5.


Please note that if the child for whom you are a primary carer wishes to apply for a derivative residence card, a separate application form and the specified application fee must be submitted for that child.


A. Your residence in the UK

4.1 What date did you start living in the UK?

D D M M Y Y Y Y

From birth

4.2 Please give details of any times at which you have been absent from the UK (from the date on which you started living in the UK)

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 Are you currently in education in the UK?

Yes No

4.4 Please give the name and address of your current school, college or other educational establishment below:

Postcode

4.5 If you are not in primary or secondary education, what course of education are you attending?

4.6 If you are not in primary or secondary education, when are you due to complete your course?

D D M M Y Y Y Y

4.7 When did you first enter education in the UK?

D D M M Y Y Y Y

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

4.8 Please give details of the educational establishments (if different from the answer you have given at question 4.4) which you have attended since entering education in the UK:

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 - please tick(Please state)


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 Any other name(s) they are or have been, known byName(s) Dates during which they have





4.14 Their date of birth

D D M M Y Y Y Y

EEA national’s gender and relationship status






Divorced Separated



EEA national’s place of birth and nationality



4.19 Nationality

4.20 Evidence of EEA nationality submitted:

valid passport issued by an EEA state

valid EEA national ID card

4.21 Passport or ID card number:

4.22 Do they have, or did they ever have a registration certificate issued by the Home Office?Yes No

4.23 If you have answered yes to question 4.21 above, please give the registration certificate number

4.24 Do they also hold British citizenship?

Yes No



Yes No

4.26 If Yes, please give details below:

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

* If relevant nationality or citizenship still held, please write ‘present’.

EEA national contact details

4.27 Please give the EEA national’s home address in the UK, if different from the address given in section 1.

Postcode

4.28 If you do not know their current address, please provide the last known address for the EEA national:

Postcode

D. Your relationship to the EEA national former worker

4.29 Please tick one of the following boxes to indicate which evidence you have submitted to demonstrate your relationship to the EEA national.

Birth certificate

Adoption certificate

Please see section 9 for further information on evidence you can submit to demonstrate your relationship to the EEA national.


E. The EEA national former worker’s residence in the UK4.30 What date did the EEA national former worker start living in the UK?

D D M M Y Y Y Y

4.31 Is the EEA national former worker still living in the UK?

Yes No

4.32 If you have answered no to question 4.31 above, what date did the EEA national former worker leave the UK?

D D M M Y Y Y Y

4.33 Please give details of any times at which the EEA national former worker was absent from the UK from the date at which they started living in the UK:

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 employment4.34 Did your EEA national parent exercise Treaty rights as a worker in the UK at a time when you were also residing in the UK?

Yes No

4.35 Please give details of the time(s) when your EEA national parent was exercising Treaty rights in the UK as a worker:Name and address of employer From To

You must also provide evidence of this employment – please see section 9 for further information on the evidence you can submit to demonstrate that your EEA national parent was a worker.


Section 5 - Primary carer of a child of an EEA national former worker where the child is in education in the UK (‘Ibrahim/Teixeira’)If you are applying as the primary carer of a child of an EEA national former worker where that child is in education in the UK (‘the child’), you must complete this section and section 4 of this form. If you do not, your application may be delayed or refused.You must also complete sections 7 - 10Please note that if the child for whom you are a primary carer wishes to apply for a derivative residence card, a separate application form and the specified application fee must be submitted for that child.We strongly recommend that you enclose all applications in the same envelope, and include details of all applicants in section 1C of each application form.


the sole primary carer of the child

a joint primary carer who shares caring responsibility for the child equally with another person

A. The child’s personal detailsPhotograph(s)Enclose a passport-sized photograph of the child for whom you are the primary carer with their full name written clearly on the back. Please place the photograph in a small sealed envelope and attach it with a staple or paper clip at the right-hand side.Please make sure that the staple or paper clip does not damage or mark the photograph.All photographs must be as specified in the photograph guidance. A copy of the photograph guidance can be found at: www.gov.uk/photos-for-passports

The child’s name5.2 Title - please tick


5.3 Full name as shown in their passport (or national identity card, if they are an EEA national)

5.4 Surname or family name as shown in their passport (or national identity card, if they are an EEA national)







The child’s gender and relationship status





Divorced Separated



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



5.11 Nationality



Yes No





Child’s contact details

5.15 Please give the child’s home address in the UK, if different from the address given in section 1.

Postcode

B. Your relationship to the child

5.16 Please tick one of the following boxes to indicate your relationship to the child of whom you are the primary carer:

parent

legal guardian

grandparent

sibling

Please note – if you are not in one of the categories set out above, you will not qualify for a right of residence as the primary carer of a child of an EEA national former worker.

Please see section 9 for information on evidence that can be submitted to demonstrate your relationship to the child.


C. Dependency

5.17 Please give details about how the child is wholly reliant on you (or you and your joint primary carer) for their care (for example, financial dependence, personal care):

5.18 Is there another person in the UK who could or does assume caring responsibility for the child?


5.19 Please give details of any other relatives of the EEA national child who are living in the UK:Full name Date of birth Nationality Relationship to the British

citizen

Parent(s) of the child

If you are applying as the primary carer of the child, and you are not their parent, please complete this section for both parents of the child.

If you are the British citizen’s parent, and the child’s other parent is not applying for a derivative residence card (and has not already been issued with a derivative residence card), please complete this section for the other parent.

Mother Father5.20 Full name5.21 Date of birth5.22 Nationality5.23 Immigration status5.24 Current address (or last know address)


5.25 What sort of contact (including face to face, by telephone or any other means) does the child have with this parent?5.26 How often does this contact take place? (For example, once a week, twice a month)5.27 When was the last known contact between the child and this parent?5.28 Is there a formal Court order in place for the child (for example, a custody agreement, residence order or contact order)? If so, please provide a copy of this agreement/order.5.29 Does this parent provide any financial support or maintenance payments for the child?5.30 If you have answered yes to question 5.29, please list these payments and the amount received per month

Primary carer of child in education aged 18 or over

If the child for whom you are the primary carer is aged 18 or over, please complete the following section.

5.31 What is the nature of the care that you provide to the child?

5.32 How many hours of care do you provide for the child each week?

5.33 What date did you start providing this care? D D M M Y Y Y Y

5.34 Who was providing care to the child before this date?


5.35 Please explain why the previous care arrangements could not continue

5.36 Does the child currently receive care from anybody else (for example, another person, the local authority or a private care provider?)

Yes No

5.37 If you have answered yes to question 5.36 above, please give details of who provides this care, what care is provided, and for how many hours each week?

5.38 If you have answered no to question 5.36 above, please give details of what enquiries have been made as to whether such care can be provided?

D. Other primary carer


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

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

• has been issued with a derivative residence card as the primary carer of the child, or

• is relying on a derivative right of residence in the UK on the basis that they are the primary carer of the child;



5.39 Their title - please tick(Please state)




5.42 Any other name(s) by which they are or have ever been known.Name(s) Dates during which they have










Postcode


5.51 Their relationship to the British citizen:



Yes No

Please note that if the other primary carer wishes to apply for a derivative residence card, they must complete their own application form and pay the specified application fee.



Section 6 - Dependent child of a primary carer who has a derivative right of residence in the UKIf you are applying as the child aged under 18 of a primary carer with a derivative right of residence in the UK, you must complete this section. If you do not, your application may be delayed or refused.

6.1 Please tick one of the following boxed to indicate the basis on which your primary carer has a derivative right of residence in the UK:

as the primary carer of a British citizen child or dependent adult

You must also complete section 2, and sections 7-10

as the primary carer of an EEA national child who is exercising their Treaty rights as a self-sufficient person in the UK

You must also complete section 3, and sections 7-10

as the primary carer of a child of an EEA national former worker where that child is in education the UK

You must also complete sections 4 and 5 and 7-10

Please note that if your primary carer wishes to apply for a derivative residence card, they must complete their own application form and pay the specified application fee.


A. Your primary carer’s personal detailsPhotograph(s)Enclose a passport-sized photograph of your primary carer with their full name written clearly on the back.




Your primary carer’s name

6.2 Title - please tick(Please state)



6.3 Full name as shown in their passport

6.4 Surname or family name as shown in their passport






The primary carer’s gender and relationship status


6.8 What is their relationship status?




Divorced Separated



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




6.11 Nationality


Yes No





The primary carer’s contact details

6.15 Please give the child’s home address in the UK, if different from the address given in section 1.

Postcode

B. Your relationship to the primary carer

6.16 Please tick one of the following boxes to indicate your primary carer’s relationship to you:

parent

legal guardian

grandparent

sibling

Please note – if your primary carer is not in one of the categories set out above, you will not qualify for a right of residence as the dependant of a primary carer with a derivative right of residence.


Please see section 9 for information on evidence that can be submitted to demonstrate your relationship to the primary carer.

C. Dependency

6.17 Please give details about how you are wholly reliant on primary carer for your care:

6.18 Is there another person in the UK or anywhere else who could or does assume caring responsibility for you?


Your Parents

If the primary carer is not your parent, please complete this section for both of your parents.

If your primary carer is your parent, and your other parent is not applying for a derivative residence card (and has not already been issued with a derivative residence card), please complete this section for the other parent.


6.20 Date of birth

6.21 Nationality

6.22 Immigration status

6.23 Current address (or last know address)6.24 What sort of contact (including face to face, by telephone or any other means) does the child have with this parent?


6.25 How often does this contact take place? (For example, once a week, twice a month)6.26 When was the last known contact between the child and this parent?6.27 Is there a formal Court order in place for the child (for example, a custody agreement, residence order or contact order)? If so, please provide a copy of this agreement/order.6.28 Does this parent provide any financial support or maintenance payments for the child?6.29 If you have answered yes to question 6.28, please list these payments and the amount received per month


Section 7 - personal history (such as criminal convictions, war crimes)This section asks you about any criminal convictions you have, any civil judgments or civil penalties made against you and details of any involvement you may have had in war crimes, genocide, crimes against humanity or terrorism. If you fail to answer all of these questions as fully and accurately as possible, your application may be refused.

It is an offence under section 26(1)(c) of the Immigration Act 1971 to make a statement or representation which is known to be false or is not believed to be true. Information given will be checked with other agencies.

7.1 Have you been convicted of any criminal offence in the UK or any other country?

Yes - continue below No - go to question 7.2

Please give details below for each criminal conviction, starting with the most recent one. If you or any dependants who are applying with you have received more than two convictions, please photocopy this page and enclose it with this form.

Note: We will carry out criminal record checks on all applicants and dependants.

In accordance with section 56A of the UK Borders Act 2007 you are required to disclose all spent or unspent convictions. This includes road traffic offences but not fixed penalty notices (such as speeding or parking tickets) unless they were part of a sentence of the court. This includes all drink-driving offences.

Criminal conviction 1

Name under which you were convicted

Country where convicted

Nature of the offence

Sentence given

Date sentenced D D M M Y Y Y Y


If you were sentenced to a period of imprisonment, what was the length of the prison sentence imposed (in months)?

months

Criminal conviction 2

Name under which you were convicted

Country where convicted

Nature of the offence

Sentence given

Date sentenced D D M M Y Y Y Y

If you were sentenced to a period of imprisonment, what was the length of the prison sentence imposed (in months)?

months

7.2 Do you have any civil judgments against you or any civil penalty under the UK immigration acts?

Yes continue below No go to question 7.3

Give details for each civil judgment or any civil penalty under the UK immigration acts, starting with the most recent one.If you have received more than two civil judgments and/or civil penalties under the UK immigration acts, please photocopy this page and enclose it with this form.

Details of judgment or civil penalty 1

Date of judgment or civil penalty D D M M Y Y Y Y

Country where judgment made


Details of judgment or civil penalty 2

Date of judgment or civil penalty D D M M Y Y Y Y

Country where judgment made

You must answer the following questions even if you have answered that you have not been convicted of any criminal offence in the UK or any other country.For help in answering these questions, please see the definitions at the end of this section.Provide more details on a separate sheet of paper if necessary and submit it with your application.

7.3 Have you ever been charged or indicted in any country with a criminal offence for which you have not yet been tried in court?

Yes Please provide details: No go to question 7.4

7.4 In either peace or war time, have you ever been involved in, or been suspected of involvement in, war crimes, crimes against humanity or genocide?


7.5 Have you ever been involved in, supported or encouraged terrorist activities in any country?


7.6 Have you ever been a member of, or given support to, an organisation which has been associated with terrorism.



7.7 Have you ever, by any means or medium, expressed views that justify or glorify terrorist violence or that may encourage others to terrorist acts or other serious criminal acts?


7.8 Have you ever engaged in any other activities which might indicate that you may not be considered to be a person of good character?

Yes Please provide details: No

DefinitionsThe following information provides guidance on actions which may constitute war crimes, crimes against humanity, genocide, or terrorist activities.

This guidance is not exhaustive. The full definitions of war crimes, crimes against humanity and genocide can be found in Schedule 8 of the International Criminal Court Act 2001 at www. legislation.gov.uk/ukpga/2001/17 or purchased from The Stationery Office (telephone 0870 600 5522). It is the your responsibility to satisfy yourself that you are familiar with the definitions and can answer the questions accurately.

War crimesGrave breaches of the Geneva Conventions committed during an armed conflict. This includes an internal armed conflict and an international armed conflict. The types of acts that may constitute a war crime include wilful killing, torture, extensive destruction of property not justified by military necessity, unlawful deportation, the intentional targeting of civilians and the taking of hostages.

Crimes against humanityActs committed at any time (not just during armed conflict) as part of a widespread or systematic attack, directed against any civilian population with knowledge of the attack. This would include offences such as murder, torture, rape, severe deprivation of liberty in violation of fundamental rules of international law and enforced disappearance of persons.

GenocideActs committed with intent to destroy, in whole or in part, a national, ethnical, racial or religious group.


Terrorist activitiesAny act committed, or the threat of action, designed to influence a government or intimidate the public and made for the purposes of advancing a political, religious or ideological cause and that involves serious violence against a person; that may endanger another person’s life; creates a serious risk to the health or safety of the public; involves serious damage to property; 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; prepares for terrorism; promotes or encourages terrorism (including the unlawful glorification of terrorism); or is otherwise concerned in terrorism.


Section 8 - Public funds (state benefits)This section asks for information about any public funds or state benefits (also known as ‘social assistance’) you are claiming, or have claimed, or that your sponsor is claiming, or has claimed, since you have lived in the UK.

Note: you only have to complete this section if you’re applying as the primary carer of a child

8.1 Are you claiming, or have you/has your sponsor claimed, since living in the UK, any of the public funds or state benefits listed in the table below?

Yes No

8.2 If you have answered yes, please complete the table below to show the amount you/your sponsor receive(s), or received, each week/month and for how long the benefit has been paid.

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

Child benefit

Child tax credit

Council tax benefit

Council tax reduction


Disability living allowance

Employment and support allowance – income-related (work-related activity group)Employment and support allowance – income-related (support group)

Employment and support allowance – contribution-based (work-related activity group)Employment and support allowance – contribution-based (support group)

Housing benefit

Homelessness and housing assistance

Income support

Jobseeker’s allowance – income-based

Jobseeker’s allowance – contribution-based

Personal independence payment

Severe disablement allowance


Social Fund payment

State pension credit

Working tax credit

Universal credit

8.3 If there are any benefits you have claimed not in the list above, or if you wish to provide any other information, please use the box below.



Section 9 - Documents and evidenceYou must submit proof of your identity and nationality and proof that you have a derivative right of residence. If you do not, your application will be invalid and will be returned to you.This section provides guidance on what documents to submit. Please also submit photocopies of all original documents submitted as well as the original documents.If you receive bank statements in online/electronic format only, ask your bank to stamp each page with their official stamp. If you wish to send any documents which are not in English or Welsh, you must get the document translated by a qualified professional translator. Ask the translator or translation company to confirm in writing on the translation:

• 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

Please tick the relevant boxes below to show what documents (and, where relevant, how many of each) you’re submitting. If you’re submitting any documents not listed in the relevant section, 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?

PhotographsTwo passport sized photographs with your name written on the back and which conform to the standards on www.gov.uk/photos-for-passports

Proof of your identityYour original valid passport, or

Your original valid EEA national identity card

Make sure that you have signed your passport.

You must provide the relevant identity documents. If you’re not able to submit a valid passport or EEA national identity card due to circumstances beyond your control, you must explain why not and submit any alternative evidence of your identity and nationality (see also section 1.16).Alternative evidence submitted:


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

Their valid passport, or

Their valid EEA national identity card

You must provide the relevant identity documents. If you’re not able to submit a valid passport or EEA national identity card for the person for whom you are the primary carer due to circumstances beyond your control, you must explain why not and submit any alternative evidence of your identity and nationality (see also section 1.16).Alternative evidence submitted:

Photographs

A passport sized photograph with their name written on the back and which conforms to the standards on www.gov.uk/photos-for-passports

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

Adoption certificate(s)

Court order detailing legal guardianship

Marriage certificate

Civil partnership certificate

Evidence of caring responsibilitiesResidence or custody order

NHS letters

School letters

Social services letters

Other (please give details)


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

Valid British passport

Certificate of registration as a British citizen issued by the Home Office

Nationality status letter issued by the Home Office confirming British citizen statusCertificate of naturalisation as a British citizen issued by the Home Office

Certificate of entitlement to a right of abode in the United Kingdom issued under section 2(1)(a) of the Immigration Act 1971UK birth certificate showing birth in the UK before 1 January 1983

UK birth certificate showing birth in the UK on or after 1 January 1983 and evidence that either parent was either a British citizen or settled in the UK at the time of the birth.

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

Itemised bank statements covering at least the last three months

Building society pass book

Evidence of receipt of a pension

Evidence of income from rental property

Wage slips from lawful employment

Evidence of income from lawful self-employment

If a relative, friend or other person or organisation is financially supporting the child, a signed and dated letter from that person or organisation confirming that they are supporting you and for how long. You must also submit evidence of their finances as above.


Any other relevant evidence of the financial resources available to you (please list):

Photographs

A passport sized photograph with their name written on the back and which conforms 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)

If the child has private medical insurance, a schedule or other document from the insurance provider outlining the level of cover. This must cover the child and their primary carer(s) for the majority of risks while they are in the UKValid European Health Insurance Card (EHIC) issued by an EEA Member State (other than the UK), together with a statement confirming that you do not intend to live permanently in the UKForm S1

Form S2

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

Birth certificate

Adoption certificate

Evidence of EEA nationality of the former worker Valid EEA passport

Valid EEA national ID card

Registration certificate issued by the Home Office

Evidence of the EEA national’s employment


A letter from the EEA national’s previous employer confirming the dates of employment. This must be signed and dated by the employer, include the employer’s contact details, and be on the letter-headed paper of the employer. Wage slips, and/or

Your bank statements showing receipt of your wages

Signed and dated contract of employment

Form P45

Most recent P60

Letter of redundancy or dismissal from the employer

Letter from the employer accepting your resignation

Employment tribunal judgment

Any other evidence (please list):

The evidence submitted should demonstrate that the EEA national was a worker at a time when the child was residing in the UK.

Evidence of the EEA national’s residence in the UK

Tenancy agreement(s)

Mortgage agreements(s)

Bank statement(s)

Utility bills

NHS letters


The evidence submitted should demonstrate that the EEA national was resident in the UK at a time when the child was in education in the UK.

Evidence of the child’s residence in the UKSchool letters

NHS letters


Residence/custody orders

Any other evidence (please list)

The evidence submitted should demonstrate that the child was residing in the UK at a time when the EEA national was a worker.

Evidence that the child is in education in the UKSchool letters/reports

Local Education Authority letters


The evidence should demonstrate that the child was in education in the UK at a time when the EEA national former worker was residing in the UK, and that the child is currently in education in the UK

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

Birth certificate(s)

Adoption certificate(s)

Court order detailing legal guardianship

Evidence of identity of your primary carerValid passport

Valid EEA national ID card

You must provide the relevant identity documents. If you’re not able to submit a valid passport or EEA national identity card for your primary carer due to circumstances beyond your control, you must explain why not and submit any alternative evidence of your identity and nationality (see also section 1.16).Alternative evidence submitted:


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

NHS letters

School letters

Social services letters

Any other evidence (please give details):

Other relevant evidence not listed above How many?

If you have submitted any other documents with your application not listed above, please list them below:

Now go to section 10 (declaration).


Section 10 - DeclarationPlease read the declaration below and sign it. It should be signed by you (the applicant) and not by a representative or other person acting on your behalf. If you are under 18, your parent or guardian may sign it.

If the declaration is not completed, we may reject your application.

I hereby apply for a derivative residence card. The information I have given in this form is complete and is true to the best of my knowledge.

I confirm that the photographs submitted with this form are a true likeness of me, as named on the back of each photograph, and that I have had the opportunity to see the Home Office photograph guidance.

I confirm that if, before this application is decided, there is a material change in my circumstances or new information relevant to this application becomes available, I will inform the Home Office.

I understand that all information provided by me to the Home Office will be treated in confidence but that it may be disclosed to other government departments, agencies, local authorities, the police, foreign governments and other bodies for immigration purposes or to enable them to perform their functions, and that, if such bodies provide the Home Office with any information about me which may be relevant for immigration purposes, it may be used in reaching a decision on my application or on whether I have a right to reside in the UK.

I understand that my details may in certain circumstances be passed to fraud prevention agencies to prevent and detect fraud and money laundering. I also understand that such agencies may provide the Home Office with information about me. Further details explaining when information may be passed to or from fraud prevention agencies and how that information may be used can be obtained from the Home Office website.

I understand that documents provided in support of this application will be checked for authenticity, and that false documents will be retained and may result in my application being refused and in my prosecution and subsequent removal from the UK.

I understand that the Home Office may also use the information provided by me for training purposes.

I am aware that it is an offence to make a statement or representation which I know to be false or do not believe to be true, or to obtain, or seek to obtain a registration certificate by means which include deception.

I understand that if I am informing the Home Office that I have changed my gender, these details may in certain circumstances be shared with other parts of the Home Office. I consent to this, where necessary, and understand that this information will only be shared in limited circumstances relating to identity and security in line with section 22 of the Gender Recognition Act. I am aware they will otherwise be treated in confidence and that my rights under the Equality Act 2010, Data Protection Act 2018 and Article 8 of the European Convention on Human Rights will be unaffected.

Signed Date D D M M Y Y Y Y


Identity document checklistPlease complete the table below to help us check that we have received your identity documents and to keep a record of them while they are with us.

Documents How many?

Passports

National identity cards

Biometric residence permits (BRPs)

Birth certificates

Marriage/civil partnership certificates

Driving licence (paper or photo)

Deed poll

Please make sure you send your application to the correct address as shown on the front of this form. Sending it to any other address will delay your application.