1. Healthcare

DRF1
Derivative Residence Card
Version 01/2015
Application for a derivative residence
card as a person with a derivative right of
residence under EU law.
This form is to be used for applications made on or after 30 January 2015
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’),
•
the primary carer of a self-sufficient EEA national child (‘Chen’)
• the child of an EEA national former worker where the child is in education in the UK
(‘Ibrahim/Teixeira’)
• the primary carer of a child of an EEA national former worker where the child is in
education in the UK (‘Ibrahim/Teixeira’), or
• the dependent child aged under 18 of a primary carer in one of the categories
above.
The fee
There is a fee of £55 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 for further information.
Each person claiming a derivative right of residence must complete their own application form
and pay the specified fee.
Please read the guidance notes for further information on who can apply on this form.
Where to send your completed application
Applications on this form cannot be made at our Premium Service Centres.
You must send the completed application form, supporting documents, and payment of £55 to
the address below:
Home Office – Derivative rights applications
PO Box 639
Durham
DH1 9LB
Sending it to any other address may delay your application.
WORKING TOGETHER TO PROTECT THE PUBLIC
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Payment Guidance
The Fee
There is a fee of £55 for this application.
Please note that your application will be rejected as invalid if you do not pay the specified fee.
How you can pay
You can pay by any of the following methods:
•Cheque/Bankers Draft (postal applications only)
•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 orders
You 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 page
To 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.
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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.
AMERICAN EXPRESS
AUTHORISED SIGNATURE
4567 123
CVV
123
CVV
1234
1234 123456 12345
1234
Consideration process
•If the payment submitted does not cover the full cost of your application, it will be an invalid
application and the form, together with any documentation submitted, will be returned to you.
•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 five
working days for payments made by cheque to clear, credit/debit cards and postal orders will
clear immediately.
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Payment details - DRF1
Please 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 - £55
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
11. Card details
Valid from
/
12. Cardholders signature
Expiry date
/
CVV number
Issue No. if
available
Date
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Section 1 - Applicant’s details
A. Category of application
1.1 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
across this box 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 name
1.2 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
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1.5 Any other name(s) by which you are or have been known
Name(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 place of birth, date 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)
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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
National indentity card
document
(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:
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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 opposite 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
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1.25 Is the address in 1.24 the address of your representative or authorised immigration
adviser?
Yes
No
Not applicable
1.26 If you have answered yes to question 1.25, how is your representative authorised? if you
are not sure, ask your representative.
Regulated by the Office of the Immigration Services Commissioner (OISC)
OISC reference number:
Regulated by the Law Society or other relevant professional body or regulator
Registered or authorised in an EEA state
Supervised
Exempt, or employed or supervised by an exempt person
Specified by Order
I don’t know
1.27 Your home/daytime telephone number
1.28 Your mobile number if you have one
1.29 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:
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.
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C. Family members applying with you
If 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
Now go to section 2
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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 details
Photographs
Enclose at least one 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(s) in a small sealed envelope and attach it across this box 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(s).
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
British citizen’s name
2.3 Title - please tick
(Please state)
Mr
Mrs
Miss
Ms
Master
Other
2.4 Full name as shown in their passport
2.5 Surname or family name as shown in their passport
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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?
Marriage/civil partnership
Divorce
Other (please state)
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
Civil partner
Surviving civil partner
Single
Unmarried partner
Divorced
Separated
Widow / widower
Separation order
Other (please state)
British citizen’s place of birth, date of birth and nationality
2.10 Village, town or city of birth
2.11 Country of birth
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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
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2.16 If Yes, please give details below:
Nationality or citizenship
Dates held
From (DD/MM/YYYY
To (DD/MM/YYYY
* 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 citizen
2.18 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
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.
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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
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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
Father
2.22 Full name
2.23 Date of birth
2.24 Nationality
2.25 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
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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?
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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)
Mr
Mrs
Miss
Ms
Master
Other
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
used this/these name(s)
2.45 Their date of birth
D D
2.46 What is their gender?
Male
M M
Y Y Y Y
Female
2.47 What is their nationality?
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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.
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Section 3 - Primary carer of an EEA national child
who is exercising Treaty rights in the UK as a selfsufficient 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
3.1 Please tick one of the following boxes to confirm whether you are applying as:
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 details
Photograph(s)
Enclose at least one passport-sized photograph of the EEA national child for whom you are the
primary carer with their full name written clearly on the back. Please place the photograph(s) in a small sealed envelope and attach it across this box 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(s).
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
EEA national child’s name
3.2 Title - please tick
(Please state)
Mr
Mrs
Miss
Ms
Master
Other
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
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3.5 Any other name(s) they are or have been, known by
Name(s)
Dates during which they have
used this/these name(s)
3.6 If they have changed their name, why did they change it?
Marriage/civil partnership
Divorce
Other (please state)
EEA national child’s gender and relationship status
3.7 What is their gender?
Male
Female
3.8 What is their relationship status?
Married
Dissolved Civil partnership
Civil partner
Surviving civil partner
Single
Unmarried partner
Divorced
Separated
Widow / widower
Separation order
Other (please state)
EEA national child’s place of birth, date of birth and nationality
3.9 Village, town or city of birth
3.10 Country of birth
3.11 Nationality
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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
3.16 Do they currently hold, or have they ever held, any other nationality or citizenship?
Yes
No
3.17 If Yes, please give details below:
Nationality or citizenship
Dates held
From (DD/MM/YYYY
To (DD/MM/YYYY
* If relevant nationality or citizenship still held, please write ‘present’.
3.18 Their date of birth
D D
M M
Y Y Y Y
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
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B. Your relationship to the EEA national child
3.20 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
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-sufficient
Sufficient resources
Please 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
Owner of financial resource
resource
EEA national child Family member living Other relative (not
in the UK
in the UK), friend or
other person
Savings
Investments
Income from rental
property
State pension
Occupational pension
Income from lawful
employment
Income from lawful
self-employment
Other - 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
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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?
Yes - give details
No
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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.
Mother
Father
3.26 Full name
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?
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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
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 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;
you must complete the following section in relation to that person.
3.37 Their title - please tick
Mr
Mrs
Miss
Ms
Master
3.38 If ‘other’, what is their title?
3.39 Their name as in their passport (or national ID card if they are an EEA national)
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3.40 Their surname as in their passport (or national ID card if they are an EEA national)
3.41 Any other name(s) by which they are or have ever been known.
Name(s)
Dates during which they have
used this/these name(s)
3.42 Their date of birth
D D
3.43 What is their gender?
Male
M M
Y Y Y Y
Female
3.44 What is their nationality?
3.45 Their place of birth – town or city and country
3.46 Their passport or travel document number
3.47 Their immigration status (if applicable)
3.48 Their Home Office reference (if applicable)
3.49 Their United Kingdom address Postcode
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3.50 Their relationship to the EEA national child:
parent
legal guardian
grandparent
aunt or uncle
brother or sister
spouse or civil partner
3.51 Their relationship to you:
3.52 Are they also applying for a derivative residence card?
Yes
No
Now go to section 4.
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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.
You must also complete sections 7 - 10
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.
You must also complete sections 7 - 10
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.
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.
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
Date of return
Number of
departure
to UK
days absent
from UK
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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
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Course
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C. The EEA national former worker’s personal details
EEA national’s name
4.9 Title - please tick
(Please state)
Mr
Mrs
Miss
Ms
Master
Other
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 by
Name(s)
Dates during which they have
used this/these name(s)
4.13 If they have changed their name, why did they change it?
Marriage/civil partnership
Divorce
Other (please state)
4.14 Their date of birth
D D
M M
Y Y Y Y
EEA national’s gender and relationship status
4.15 What is their gender?
Male
Female
4.16 What is their relationship status?
Married
Dissolved Civil partnership
Civil partner
Surviving civil partner
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Single
Unmarried partner
Divorced
Separated
Widow / widower
Separation order
Other (please state)
EEA national’s place of birth and nationality
4.17 Village, town or city of birth
4.18 Country of birth
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
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4.25 Do they currently hold, or have they ever held, any other nationality or citizenship?
Yes
No
4.26 If Yes, please give details below:
Nationality or citizenship
Dates held
From (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
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E. The EEA national former worker’s residence in the UK
4.30 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
Date of return
Number of
departure
to the UK
days absent
from the UK
D. The EEA national former worker’s employment
4.34 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.
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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 - 10
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.
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.
5.1 Please tick one of the following boxes to confirm whether you are applying as:
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 details
Photograph(s)
Enclose at least one 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(s) in a small sealed envelope and attach it across this box 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(s).
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 name
5.2 Title - please tick
(Please state)
Mr
Mrs
Miss
Ms
Master
Other
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)
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5.5 Any other name(s) they are or have been, known by
Name(s)
Dates during which they have
used this/these name(s)
5.6 If they have changed their name, why did they change it?
Marriage/civil partnership
Divorce
Other (please state)
The child’s gender and relationship status
5.7 What is their gender?
Male
Female
5.8 What is their relationship status?
Married
Dissolved Civil partnership
Civil partner
Surviving civil partner
Single
Unmarried partner
Divorced
Separated
Widow / widower
Separation order
Other (please state)
The child’s place of birth, date of birth and nationality
5.9 Village, town or city of birth
5.10 Country of birth
5.11 Nationality
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5.12 Do they currently hold, or have they ever held, any other nationality or citizenship?
Yes
No
5.13 If Yes, please give details below:
Nationality or citizenship
Dates held
From (DD/MM/YYYY
To (DD/MM/YYYY
* If they still hold the relevant nationality or citizenship, please write ‘present’.
5.14 Their date of birth
D D
M M
Y Y Y Y
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
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.
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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?
Yes - give details
No
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
Father
5.20 Full name
5.21 Date of birth
5.22 Nationality
5.23 Immigration status
5.24 Current address (or last
know address)
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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?
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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
If there is another person in the UK who:
•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;
you must complete the following section in relation to that person.
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5.39 Their title - please tick
(Please state)
Mr
Mrs
Miss
Ms
Master
Other
5.40 Their name as in their passport (or national ID card if they are an EEA national)
5.41 Their surname as in their passport (or national ID card if they are an EEA national)
5.42 Any other name(s) by which they are or have ever been known.
Name(s)
Dates during which they have
used this/these name(s)
5.43 Their date of birth
D D
5.44 What is their gender?
Male
M M
Y Y Y Y
Female
5.45 What is their nationality?
5.46 Their place of birth – town or city and country
5.47 Their passport or travel document number
5.48 Their immigration status (if applicable)
5.49 Their Home Office reference (if applicable)
5.50 Their United Kingdom address Postcode
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5.51 Their relationship to the British citizen:
5.52 Their relationship to you:
5.53 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.
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Section 6 - Dependent child of a primary carer who
has a derivative right of residence in the UK
If 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 selfsufficient 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.
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.
A. The child’s personal details
Photograph(s)
Enclose at least one passport-sized photograph of your primary carer with their full name written
clearly on the back. Please place the photograph(s) in a small sealed envelope and attach it across this box 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(s).
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 primary carer’s name
6.2 Title - please tick
(Please state)
Mr
Mrs
Miss
Ms
Master
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Other
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6.3 Full name as shown in their passport
6.4 Surname or family name as shown in their passport
6.5 Any other name(s) they are or have been, known by
Name(s)
Dates during which they have
used this/these name(s)
6.6 If they have changed their name, why did they change it?
Marriage/civil partnership
Divorce
Other (please state)
The primary carer’s gender and relationship status
6.7 What is their gender?
Male
Female
6.8 What is their relationship status?
Married
Dissolved Civil partnership
Civil partner
Surviving civil partner
Single
Unmarried partner
Divorced
Separated
Widow / widower
Separation order
Other (please state)
The primary carer’s place of birth, date of birth and nationality
6.9 Village, town or city of birth
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6.10 Country of birth
6.11 Nationality
6.12 Do they currently hold, or have they ever held, any other nationality or citizenship?
Yes
No
6.13 If Yes, please give details below:
Nationality or citizenship
Dates held
From (DD/MM/YYYY
To (DD/MM/YYYY
* If they still hold the relevant nationality or citizenship, please write ‘present’.
6.14 Their date of birth
D D
M M
Y Y Y Y
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 relationship to the child of whom
you are the primary carer:
parent
legal guardian
grandparent
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.
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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?
Yes - give details
No
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.
Mother
Father
6.19 Full name
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?
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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
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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 1.1
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
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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
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
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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.
Yes
Please provide details:
No
go to question 7.5
7.5 Have you ever been involved in, supported or encouraged terrorist activities in any country.
Yes
Please provide details:
No
go to question 7.6
7.6 Have you ever been a member of, or given support to, an organisation which has been
associated with terrorism.
Yes
Please provide details:
No
go to question 7.7
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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.
Yes
Please provide details:
No
go to question 7.8
7.8 Have you ever engaged in any other activities which might indicate that you may not be
considered to be persons of good character.
Yes
Please provide details:
No
go to question 1.9
Definitions
The 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 crimes
Grave 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 humanity
Acts 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.
Genocide
Acts committed with intent to destroy, in whole or in part, a national, ethnical, racial or religious
group.
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Terrorist activities
Any 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 terrorism
An 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.
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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
Date you/
Date you/
you/they
they
they
receive
started
stopped
each week/ receiving
receiving
month –
this benefit this benefit
please
(if you no
specify
longer
frequency)
receive it)
Attendance allowance
Carer’s allowance
Child benefit
Child tax credit
Council tax benefit
Council tax reduction
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Disability living allowance
Employment and support
allowance – incomerelated (work-related
activity group)
Employment and support
allowance – incomerelated (support group)
Employment and support
allowance – contributionbased (work-related
activity group)
Employment and support
allowance – contributionbased (support group)
Housing benefit
Homelessness and
housing assistance
Income support
Jobseeker’s allowance
– income-based
Jobseeker’s allowance
– contribution-based
Personal independence
support
Severe disablement
allowance
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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.
Now go to section 9
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Section 9 - Documents and evidence
You must submit proof of your identity and nationality and proof that you have a derivative right
of residence. If you do not, your application may be delayed or refused.
This section provides guidance on what documents to submit.
Unless otherwise stated, please send original documents only. Photocopies are not acceptable. If you’re unable to send the original, please explain why. We are unlikely to be able to approve
your application without sight of the original document.
Please also submit photocopies of all 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
How
many?
All applicants should complete this section
Photographs
Two 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 identity
Your valid passport, or
Your valid EEA national identity card
Make sure that you have signed your passport.
If you’re not able to submit a valid passport or EEA national identity card,
you must explain why not and submit any alternative evidence of your
identity and nationality (see also section 1.16).
Alternative evidence submitted:
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2 – Primary carers
Please complete this section if you have completed sections 2, 3 or 5 of this
form as a primary carer.
How
many?
If you have completed section 6 if this form as the dependent child of a
primary carer, you should also complete this section for your primary carer.
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
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, 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 relationship to the person for whom you are the primary carer
Birth certificate(s)
Adoption certificate(s)
Court order detailing legal guardianship
Marriage certificate
Civil partnership certificate
Evidence of caring responsibilities
Residence or custody order
NHS letters
School letters
Social services letters
Other (please give details)
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3 – Primary carer of a British citizen (‘Zambrano’ cases)
Please complete this section if you have completed section 2 of this form
How
many?
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.
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
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.
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
How
many?
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.
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.
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Any other relevant evidence of the financial resources available to you
(please list):
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 UK
Valid 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 UK
Form S1
Form S2
Form S3
5 – Child of an EEA national former worker, or the primary carer of such a
child (‘Ibrahim/Teixeira’ cases)
How
many?
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.
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
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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
Any other evidence (please list):
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 UK
School letters
NHS letters
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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 UK
School letters/reports
Local Education Authority letters
Any other evidence (please list):
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 carer
Valid passport
Valid EEA national ID card
If you’re not able to submit a valid passport or EEA national identity card
for your primary carer, you must explain why not and submit any alternative
evidence of your identity and nationality (see also section 1.16).
Alternative evidence submitted:
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Evidence of your primary carer’s caring responsibilities for you
Residence/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)
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Section 10 - Declaration
Please 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 should sign it.
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.
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 Home Office colleagues. 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 1998 and Article 8 of the European Convention on Human
Rights will be unaffected.
Signed
Date
D D
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Identity document checklist
Please 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.
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