Fill - Free fillable Form EEA(PR) Application for a document certifying permanent residence PDF form

EEA(PR)

Application for a document certifying

permanent residence or permanent

residence card under the EEA Regulations

Who this form is for

Use this application form if you wish to apply for a document certifying permanent residence

(if you’re an EEA national) or permanent residence card (if you’re a non-EEA national) as

conrmation of a right of permanent residence under the Immigration (European Economic

Area) Regulations 2016 (‘the EEA Regulations’).

Any reference on this form to EEA nationals includes Swiss nationals.

Eligibility

You must normally have lived in the UK for a continuous period of 5 years as either:

•

an EEA national ‘qualied person’ (worker, self-employed, self-sucient, student or jobseeker)

• a family member or extended family member* of an EEA national qualied person or

permanent resident

• a former family member of an EEA national if you’ve retained your right of residence after

the EEA national died or left the UK, or your/their marriage or civil partnership ended in

divorce, annulment or dissolution

• a family member of a British citizen who worked or was self-employed in another EEA state

before returning to the UK (‘Surinder Singh’ cases)

You can also qualify if you are either:

• an EEA national former worker or self-employed person who has ceased activity in the UK

because you have retired, are permanently incapacitated, or you’re now working or self-

employed in another EEA state but still retain your residence in the UK

•

the family member or extended family member* of an EEA national who has ceased activity

• the family member or extended family member* of an EEA national former worker or self-

employed person who has died

Version 03/2019

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

The Home Oce 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.

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*You can only apply as an extended family member if you’ve held valid residence documentation

(registration certicate, residence card, or EEA family permit) throughout the relevant qualifying

period.

Replace or renew your permanent residence document

You can also use this form if you have previously been issued with a document certifying

permanent residence or permanent residence card (or equivalent document) and want to replace

it because it has been permanently lost or stolen, or renew it because it has expired.

The fee

There is a fee of £65 for each person applying for a document certifying permanent residence or

permanent residence card. See the payment guidance notes, enclosed with this form, for further

information.

Your family members

You can include your family members (including extended family members) in this application if

they also qualify for permanent residence.

You must pay an additional £65 for each family member you include. If your payment does not

cover you and your family members, we will reject your application and return it to you without

consideration.

Biometric information for non-EEA nationals

If you are a non-EEA national applying for a permanent residence card, you must give your

biometric information (ngerprints and a digital photograph) before your application will be

considered. If you do not, we may reject your application. See pages 7-13 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 specied in section 18 of this form and the

guidance notes on our website at:

www.gov.uk/government/publications/apply-for-a-document-certifying-permanent-residence-or-

permanent-residence-card-form-eea-pr.

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

you, leave it blank.

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

• front page of the form

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

required, the biometric section).

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Where to send your completed application

You must send your completed application form, supporting documents, and payment of £65 to

the address below:

Department 600

UKVI

The Capital

Old Hall Steet

Liverpool

L3 9PP

Sending it to any other address will delay your application. If you want to conrm that we have

received your application, we recommend that you send it by special or recorded delivery and

track it on the Royal Mail website: www.royalmail.com/track-your-item

Payment Guidance

The Fee

There is a fee of £65 for this application. If you wish to include any family members in this

application, the fee increases by £65 for each family member included, as explained in the table

below:

Number of applicants Fee

You, no family members £65

You and 1 family member £130

You and 2 family members £195

You and 3 family members £260

You and more than 3 family members Add £65 to the amount above for each

additional family member

You must pay the specied fee. If you do not include valid payment details, or your payment

does not cover the full cost of the application, we will reject your application and return it to you

without further consideration.

How you can pay

You 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 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.

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Cheques and postal orders

You must make the cheque or postal order payable to ‘Home Oce’ 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 gures) 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.

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 123

AUTHORISED SIGNATURE

CVV

123

AMERICAN EXPRESS

1234

1234 123456 12345

CVV

1234

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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 Oce or its payment processing

agent, regardless of the outcome of the application. If your application contains errors or is

missing information it may be 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 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.

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Payment details - EEA(PR)

Please complete this page in block capitals and black ink after rst 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.

Single applicant - no family

members

£65

Main applicant and two family

members

£195

Main applicant and one family

member

£130

Main applicant and three family

members

£260

If more than 3 family members are applying with you, please state the number in the space

below and enter the correct amount specified in the payment guidance in the box.

Main applicant and ............... family members

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 Oce’)

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. if

11. Card details / / available

12. Cardholders signature Date

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Biometric information for non-EEA nationals: form

EEA(PR)

Note: this section applies to non-EEA nationals applying for a permanent residence card only.

Do not complete this section if you are an EEA national applying for a document certifying

permanent residence – proceed straight to section 1 instead.

If you are, or anyone included in this application is, a non-EEA national applying for a permanent

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 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 (ngerprints 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 (and any non-EEA family members included in your application) to make an appointment

at a designated Post Oce to have your biometric information recorded. You will be charged an

additional handling fee for this service, payable to the Post Oce 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

Denitions

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 either:

• a residence card (biometric format) conrming your right to reside under the EEA Regulations

• a biometric residence permit conrming 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).

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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

Personal details of any non-EEA family members included in this

application

2. If you are including any non-EEA national family members in this application, please conrm

their details in the table below. If there are more than two family members, make a copy of

this table and enclose it with your application.

Number of family members included:

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Family member 1 Family member 2

Title (Mr, Mrs, Miss, Ms,

Master, Other). If ‘other’,

please specify

Full name as shown in

their passport

Nationality as shown in

their passport

Date of birth

D D M M Y Y Y Y D D M M Y Y Y Y

Village, town or city of

birth

Country of birth

Address (if dierent to the

address given in question

1 above)

Current or previous residence card (biometric format) or biometric

residence permit

3. Have you, or has anyone included in this application, been issued with a residence card (bio-

metric 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 4 No go to question 10

Note: if you/they were last issued with a residence card under the EEA Regulations in the form

a vignette or sticker in your/their passport, travel document, or other document (such as an

‘immigration status document’), answer ‘no’ to the above question.

4. If you answered yes to question 3, please give details of your/their 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 specied below. If you need more space, make a copy of this

table and enclose it with your application.

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You Family member 1 Family member 2

Residence

card

(biometric

format)

or BRP

number

Nationality

recorded on

card or BRP

Issue date

(DDMMYYYY)

Expiry date

(DDMMYYYY)

Place of

issue

Card

or BRP

enclosed?

Yes / No Yes / No Yes / No

5. If any residence card (biometric format) or BRP referred to in the table above is not enclosed

with the application then please state where the residence card (biometric format) or BRP is

now:

Returned to Home Oce - go to question 6

Stolen - go to question 7

Lost - go to question 8

Other - go to question 9

6. If any residence card (biometric format) or BRP listed in the table above has been returned to

the Home Oce, please give details below.

Reason it was returned:

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

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7. If any residence card (biometric format) or BRP listed in the table above 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 Oce card management service:

D D M M Y Y Y Y

8. If any residence card (biometric format) or BRP listed in the table above 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 Oce card management service:

D D M M Y Y Y Y

9. If any residence card (biometric format) or BRP listed in the table above is not enclosed for

any other reason, please explain why you are unable to provide it below:

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Fingerprints in previous immigration applications

10. Have you, or has any non-EEA family member included in this application, had your/their

ngerprints 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 11

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/their

ngerprints 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

11. Do you, or does any non-EEA national family member included in this application, have a

medical or physical condition which may require special arrangements for your/their 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.

Applicants under the age of 16

12. Are you, or is any non-EEA family member included in this application, under the age of 16?

Yes answer questions

13 to 14

No go to question 15

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13. 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

(if you are under 16) or the child when you/they attend your/their biometric appointment. If

there are more than 2 children, make a copy of this table and include with your application.

Child 1 Child 2

Name of responsible adult

Date of birth of

responsible adult

D D M M Y Y Y Y D D M M Y Y Y Y

Nationality of responsible

adult

Relationship of

responsible adult to child

Note: The responsible adult accompanying any child under the age of 16 will need to provide

a form of photographic identication, 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 conrming that they

are a responsible adult who has a close connection to the child and has been authorised to

accompany him or her.

14. If the responsible adult is not the parent or legal guardian of the child, please explain why

your/the child’s parent or legal guardian will not be accompanying you/the child to the

appointment:

Declaration

15. As required by the Immigration (Provision of Physical Data) Regulations 2006 (as amended),

I conrm that I am applying for a residence card (biometric format) for myself and any family

members included in this application. If I am a sole applicant under the age of 16 or if any de-

pendent child under the age of 16 is applying with me, I understand that the Home Oce may

make enquiries about any responsible adult nominated to be present when my ngerprints

and/or a photograph are taken.

Signed Date D D M M Y Y Y Y

Now go to section 1.

This page is intentionally blank

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Section 1 - Applicant’s details

You must complete this section as required, even if you have already completed the biometric

section. If you do not, your application may be delayed or even refused.

A. Document applied for

1.1 Which document are you applying for? Please tick:

I’m an EEA national and I’m applying for a document certifying permanent residence

I’m a non-EEA national and I’m applying for a permanent residence card

B. Your personal details

Photographs - You must provide 2 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 and date of birth

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

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)

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

Your gender and relationship status

1.8 What is your gender? Male Female

1.9 What is your relationship status?

Married Single

Civil partner Unmarried partner

Divorced/ Dissolved civil

partnership

Separated/ Separation order

Widow / widower Surviving civil partner

Your relationship to your sponsor

1.10 If you’re applying as the family member of an EEA national or British citizen, how are you

related to them? For example, spouse, civil partner, unmarried partner, child, parent, etc.

Note 1: if you’re applying on the basis of a retained right of residence, indicate how you were

related to your sponsor before your sponsor died or left the UK, or before your/their marriage or

civil partnership ended in divorce, annulment or dissolution.

Your nationality and place of birth

1.11 Your current nationality (as stated in your passport, travel document or national identity

card):

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

Yes No

1.13 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’.

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1.14 Place and country of birth:

Your contact details

1.15 Your home address in the UK:

Postcode

1.16 Your home/daytime telephone number: 1.17 Your mobile number if you have one:

1.18 Your name and address for all correspondence in the UK, if dierent from your home

address:

Postcode

1.19 Is the address in 1.18 the address of your representative or authorised immigration

adviser?

Yes No Not applicable

1.20 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.

Please note: if you do not provide a valid email address for you or your representative, we will be

unable to send you confirmation that we have received your application.

Your email address:

Please re-enter your email address in block capitals:

Your representative’s email address:

The Home Oce or persons acting on behalf of the Home Oce 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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Your passport or national identity card

1.21 If you are not submitting a valid passport, travel document or nationality identity card,

please say why in the box below and submit alternative evidence of your identity and nationality.

Continue on a separate sheet if necessary.

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

1.22 Home Oce reference number(s). Include any registration certicate or residence permit

number(s):

1.23 UK national insurance 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.

C. Family members included in your application

If you wish to include your (or your sponsor’s) family members (including extended family

members) in this application, please give their details below.

If you want to include more than 3 family members, enter the number below, make an extra copy

of this page, complete it with their details, and enclose it with your application.

Number of family members included:

Photographs

You must provide two identical photographs of each family member who is applying. Write the

family member’s full name on the back of each photograph and enclose both photographs

1.24 Family member’s full name:

1.25 Nationality:

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1.26 Date of birth:

1.27 Gender -

please tick

Male Female

D D M M Y Y Y Y

1.28 Home oce reference number:

1.29 Relationship to sponsor:

Document applied for (please tick):

Document certifying permanent residence (EEA national)

Permanent residence card (non-EEA national)

1.30 Family member’s full name:

1.31 Nationality:

1.32 Date of birth:

1.33 Gender -

please tick

Male Female

D D M M Y Y Y Y

1.34 Home oce reference number:

1.35 Relationship to sponsor:

Document applied for (please tick):

Document certifying permanent residence (EEA national)

Permanent residence card (non-EEA national)

1.36 Family member’s full name:

1.37 Nationality:

1.38 Date of birth:

1.39 Gender -

please tick

Male Female

D D M M Y Y Y Y

1.40 Home oce reference number:

1.41 Relationship to sponsor:

Document applied for (please tick):

Document certifying permanent residence (EEA national)

Permanent residence card (non-EEA national)

If you’re applying as a family member or extended family member, go to section 2. Otherwise, go

to section 3.

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Section 2 - Your sponsor

Complete this section with details of your sponsor if, during the relevant qualifying period, you

have mainly had a right of residence as a family member or extended family member, or if you’re

applying on the basis that you have retained your right of residence.

Note: you don’t have to complete this section if you’re applying to replace a lost or stolen

permanent residence document, or renew an expired permanent residence document - go

straight to section 3.

‘Sponsor’ means the person from whom you derive your right of residence in the UK and who is

your:

• EEA national family member or extended family member who is, or has been, a qualied

person or who has permanent residence

• EEA national former family member who was a qualied person or had permanent residence

(if you’re applying in the retained right of residence category) or

• British citizen family member who has exercised free movement rights in an EEA state other

than the UK (if you’re applying under the ‘Surinder Singh’ route)

‘Relevant qualifying period’ means the period required to acquire permanent residence. This is

normally 5 years, unless you’re applying as the family member of an EEA national who ceased

activity, or who has died.

Photographs - Enclose at least one passport-sized photograph of your sponsor 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

If you cannot provide a photograph of your sponsor because they have died, left the UK, or

you’re unable to contact them, tick the box below:

Your sponsor’s name and date of birth

2.1 Title - please tick:

(Please state)

Mr Mrs Miss Ms Master Other

2.2 Full name as shown in their passport or national identity card:

2.3 Surname or family name as shown in their passport or national identity card:

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

Name(s) Dates during which they have

used this/these name(s)

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

Marriage/civil partnership Divorce

Other (please state):

2.6 Date of birth: D D M M Y Y Y Y

Your sponsor’s gender and relationship status

2.7 What is their gender? Male Female

2.8 What is their relationship status?

Civil partner Married

Single Unmarried partner

Divorced/ Dissolved civil

partnership

Separated/ Separation order

Widow / widower Surviving civil partner

Your sponsor’s nationality and place of birth

2.9 Their current nationality (as stated in their passport or national identity card)

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

Yes No

2.11 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’.

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2.12 Place and country of birth:

Evidence of your sponsor’s identity and nationality

2.13 If you are not submitting a valid passport, travel document or nationality identity card,

please say why in the box below and submit alternative evidence of your identity and nationality.

Continue on a separate sheet if necessary.

Your sponsor’s personal reference numbers

2.14 Home Oce reference number(s):

2.15 UK national insurance number:

If your sponsor does not have any of the above reference numbers, please write ‘N/A’ (not

applicable) in the relevant box or leave it blank.

Your sponsor’s contact details

2.16 Please give your sponsor’s home address in the UK, if dierent from your address given

in section 1.

Postcode

Now go to section 3.

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Section 3 - About your application

Complete this section to indicate the basis on which you’re applying for a document certifying

permanent residence or permanent residence card and then complete the relevant sections as

directed.

Category of application

3.1 Please tick to indicate the basis on which you’re applying for permanent residence:

I’ve previously been issued with a document certifying permanent residence, permanent

residence card, or equivalent document, and wish to replace that document because it’s

been lost or stolen, or renew it because it’s expired.

Complete sections 4, 17, 18 and 19 only.

I’ve lived in the UK for a continuous period of ve years as an EEA national qualied person,

the family member or extended family member of a qualied person, or a combination of

these.

Complete sections 5, 9, 16, 17, 18 and 19. (If you are or have been a family member or

extended family member, also complete the relevant section(s) as indicated in question 3.2

below.)

I’m an EEA national who ceased activity (stopped work or self-employment) due to

retirement, permanent incapacity or because I’m now active as a worker or self-employed

person in another EEA state.

Complete sections 5, 7, 9, 16, 17, 18, and 19.

I’m the family member or extended family member of an EEA national who ceased activity.

Complete sections 5, 7, 9, 16, 17, 18, and 19 (and the relevant section(s) as indicated in

question 3.2 below).

I’m the family member or extended family member of an EEA national former worker or self-

employed person who has died.

Complete sections 5, 6, 9, 16, 17, 18, and 19 (and the relevant section(s) as indicated in

question 3.2 below).

I’ve retained my right of residence after my EEA national family member died or left the UK,

or their marriage or civil partnership ended in divorce, annulment or dissolution, and I’ve lived

in the UK for a continuous period of ve years (including time spent as a family member).

Complete sections 5, 8, 9, 16, 17, 18 and 19 (and the relevant section(s) as indicated in

question 3.2 below).

I’m the family member of a British citizen who exercised their free movement rights in another

EEA state before returning to the UK and I’ve lived in the UK for a continuous period of ve

years as their family member (‘Surinder Singh’ route).

Complete sections 5, 10, 17, 18 and 19 (and the relevant sections as indicated in question

3.2 below).

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Family members and extended family members

3.2 If you are (or anyone applying with you is) applying on the basis that you/they are (or have

been) a family member or extended family member during the qualifying period, tick the relevant

box(es) below and complete the relevant section(s) as directed.

I am or have been the spouse, civil partner, or unmarried or same-sex partner of the sponsor.

Complete section 11.

I am or have been the descendant (child or grandchild) aged under 21 of the sponsor, or of

the sponsor’s spouse or civil partner.

Complete section 12.

I am or have been the dependent child or grandchild aged 21 or over, parent, or grandparent

of the sponsor (or of the sponsor’s spouse or civil partner).

Complete section 13.

I’m an extended family member (relative) of the EEA national sponsor, or of their spouse or

civil partner, and I’m dependent on them and/or I’m a member of their household.

Complete section 14.

I’m an extended family member (relative) of the EEA national sponsor, or of their spouse or

civil partner, and I strictly require their personal care on serious health grounds.

Complete section 15.

Note: if you are, or have been, an extended family member of the relevant EEA national, you

must have held valid residence documentation (registration certicate, residence card or EEA

family permit) throughout the relevant qualifying period.

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

you, leave it blank.

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

front page(s) of the form and the sections of the form that you have actually completed.

In all cases, please also complete the Document Checklist on the nal page of this form.

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Section 4 - Replace or renew your permanent

residence document

Complete this section if you have previously been issued with a permanent residence document

(see below for denition) under the Immigration (European Economic Area) Regulations 2016,

2006 or 2000 (‘EEA Regulations’) but that document has been permanently lost or stolen and

you would like to replace it, or it has expired and you would like to renew it.

In this section, ‘permanent residence document’ means either:

• a document certifying permanent residence issued to an EEA national under the EEA

Regulations 2016 or 2006

• a permanent residence card issued to a non-EEA national under the EEA Regulations 2016 or

2006

• a residence permit issued to an EEA national under the EEA Regulations 2000 endorsed to

say you can stay in the UK indenitely

• a residence document issued to a non-EEA national under the EEA Regulations 2000

endorsed to say you can stay in the UK indenitely

Note: only complete this section if you still have a permanent right of residence. If the relevant

document was revoked or cancelled, or you have been outside the UK for a continuous period of

more than two years since it was issued, you cannot apply to replace or renew it and will need to

qualify for permanent residence again.

If any of your family members also wish to replace or renew their permanent residence

document, make and complete an extra copy of this section for each family member. Clearly

write the name of each family member in the space indicated.

Number of family members

Full name of family member:

About your permanent residence document

4.1 Which document do you wish to replace or renew?

Document certifying permanent residence

Residence permit endorsed to say you can stay in the UK indenitely

Permanent residence card

Residence document endorsed to say you can stay in the UK indenitely

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4.2 Give details of the document below:

Date of issue: D D M M Y Y Y Y

Document reference number:

Date of expiry (if stated): D D M M Y Y Y Y

4.3 Why do you wish to replace or renew it?

Document is permanently lost – answer questions 4.4 and 4.5 then 4.7 and 4.8

Document has been stolen – answer questions 4.4 and 4.5 then 4.7 and 4.8

Document has expired (permanent residence card only) – answer questions 4.7 and 4.8

Other reason – answer questions 4.6, 4.7 and 4.8

Document permanently lost or stolen

4.4 If the document has been permanently lost or stolen, did you report this to the police?

Yes No

If you have answered no, we cannot replace your document. The only exception to this is if

the document was retained by your national authorities (for example, when you renewed your

passport). If this is the case, give further information in 4.6 below and provide relevant evidence

– for example, a letter from your country’s embassy.

4.5 Give details of when and where you reported the loss or theft of the document

Where was it lost/stolen?

When was it lost/stolen? D D M M Y Y Y Y

Name of the police station to which you reported the loss or theft:

Date you reported it: D D M M Y Y Y Y

Crime reference number:

You must include evidence with your application – see section 18 and the guidance notes.

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Other reasons

4.6 If you have ticked ‘Other reason’ in question 4.3, give the full reason(s) below and provide

any relevant supporting evidence.

Absences from the UK

4.7 Since you were issued with your permanent residence document, have you at any time

been absent from the UK for a continuous period of more than 2 years?

Yes No

If you have answered yes, you will have lost your right to permanent residence and

should not complete this form.

4.8 If your permanent residence document was issued more than 2 years ago, give details

of all absences from the UK since the date it was issued. Continue on a separate sheet if

necessary and enclose with your application. You must also provide evidence of your continued

residence in the UK.

Country or countries visited Date of

departure

Date of return Number of

days*

* Enter whole days’ absences only. Do not include the day you left the UK or returned to the UK.

For example, if you were absent from the UK between 1 January 2014 and 31 January 2014,

enter 29 days (2 January to 30 January inclusive).

Now go to section 17.

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Section 5 - Residence in the UK and previous EEA

documentation

Complete this section with details of your and (if applicable) your sponsor’s residence in the UK

and any EEA residence documentation that you currently hold, or have previously held.

If you’re including any family members in this application, make and complete a copy of this

section for each family member, enclose it with your application, and clearly write the name of

the family member in the space provided.

Family member’s name:

A. Residence in the UK

5.1 Date you rst entered the UK

D D M M Y Y Y Y or Born in the UK

5.2 If you are applying as a family member or extended family member, or because you have

retained your right of residence, date your sponsor entered the UK

D D M M Y Y Y Y Born in UK Or not applicable

5.3 Have you (or has your sponsor, if applicable) had any absences from the UK since you/they

entered?

Yes No

If yes, please give details in the tables below. Continue on a separate sheet if necessary and

enclose with your application.

You:

Country or countries visited Date of departure Date of return Number of

days*

Your sponsor (if applicable)

Country or countries visited Date of departure Date of return Number of

days*

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* Enter whole days’ absences only. Do not include the day you left the UK or returned to the UK.

For example, if you were absent from the UK between 1 January 2014 and 31 January 2014,

enter 29 days (2 January to 30 January inclusive).

5.4 If you were or your sponsor was absent from the UK for more than 6 months in any

12-month period, please indicate the reason for the absence by ticking the relevant box below:

Military service

Other important reasons, such as pregnancy and childbirth, serious illness, study or

vocational training, or an overseas employment posting

Give further details below. Continue on a separate sheet if necessary and enclose with your

application.

B. Current or previous EEA residence documentation

5.5 Do you currently hold, or have you previously been issued with, any EEA residence

documentation listed in table below?

Yes No

If yes, please provide details below. Continue on a separate sheet if necessary.

Document Date of

issue

Date of

expiry

Document reference number

EEA family permit

Registration certicate

Residence card

Document certifying

permanent residence

Permanent residence card

Derivative residence card*

* Note: time spent in the UK with a derivative right of residence does not count towards

permanent residence.

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5.6 Were any of the above documents issued to you on the basis that you are, or were, the

family member or extended family member of the sponsor named in section 2?

Yes No

If yes, provide details below:

5.7 Have any of the above documents since been revoked or cancelled by the Home Oce?

Note: only answer ‘yes’ if you have received a formal notice from the Home Oce telling you that

it has been revoked, or if it was cancelled by a Border Force (immigration) ocer. Do not answer

‘yes’ if the document has simply expired.

Yes No

If yes, provide details below:

5.8 Are you enclosing the relevant document(s) with your application?

Yes No

5.9 If you have answered no to 5.8, please explain why you are not enclosing it/them and

provide any relevant supporting evidence (e.g. if the document was stolen, details of when you

reported it to the police, crime reference number, and evidence that you reported it, such as a

police lost property report).

Now go to—

• Section 6 if you’re the family member or extended family member of an EEA national who has

died

• Section 7 if you are, or your sponsor is, an EEA national who has ceased activity

• Section 8 if you have retained your right of residence

• Section 10 if you’re the family member of a British citizen and applying under the ‘Surinder

Singh’ judgment

• Section 9 in all other cases

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Section 6 - Family member or extended family

member of an EEA national worker or self-employed

person who has died

Complete this section if your sponsor was an EEA national worker or self-employed person

who has died and you were living with them as their family member or extended family member

immediately before their death.

Note: if you’re applying as an extended family member, you must have held valid residence

documentation (registration certicate, residence card, or EEA family permit) as the relevant EEA

national’s extended family member immediately before their death. Give details of that document

in section 5 and enclose it with your application.

6.1 Date your sponsor died D D M M Y Y Y Y

6.2 Were you (and your family members, if applicable) living with your sponsor immediately

before they died?

Yes No

6.3 What was your sponsor’s status immediately before they died?

Worker Self-employed

You must give further details of your sponsor’s activity in section 9.

6.4 Had your sponsor lived in the UK for at least 2 years immediately before they died?

Yes No

6.5 Was your sponsor’s death due to an accident at work or an occupational disease?

Yes No

If yes, give details below:

Now go to section 9.

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Section 7 - EEA national former worker or self-

employed person who has ceased activity

Complete this section if you are, or your sponsor is, an EEA national who was working or self-

employed in the UK and you or they have ‘ceased activity’ because you/they either:

• have retired

• are permanently incapacitated

• are now active as a worker or self-employed person in another EEA state but you/they still

have your/their main home in the UK

In the rest of this section, ‘relevant EEA national’ refers to the person (you or your sponsor,

whichever is applicable) who ceased activity.

Note: if you’re applying as an extended family member of a relevant EEA national who has

ceased activity, you must hold, or have held, valid residence documentation (registration

certicate, residence card, or EEA family permit), as their extended family member.

7.1 What was the relevant EEA national’s status in the UK immediately before they ceased

activity?

Worker Self-employed Other (please state)

7.2 Date the relevant EEA national ceased activity D D M M Y Y Y Y

7.3 How long had the relevant EEA national been living in the UK before they ceased activity?

7.4 How long had the relevant EEA national been working or self-employed in the UK before

they ceased activity?

Note: you must give details of your/your sponsor’s activity in the UK before you/they ceased

activity in section 9.

7.5 If you are the family member or extended family member of the relevant EEA national, were

you (and your family members, if applicable) living in the UK immediately before the relevant

EEA national ceased activity?

Yes No

If no, give details of any family members who were not in the UK and where they were:

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7.6 Reason the relevant EEA national ceased activity – please tick:

Retired when they reached state pension age – go to section 9

Took early retirement (worker only) – go to section 9

Permanent incapacity to work – answer questions 7.7 and 7.8 below

Now active in another EEA state – answer questions 7.9 to 7.16 below

Permanent incapacity

7.7 Was the incapacity the result of an industrial accident or occupational disease?

Yes No

If yes, give details below:

7.8 If you answered yes to 7.7, does the relevant EEA national receive a pension paid in part or

in full by an institution in the UK?

Yes No Not applicable

If yes, give details below:

Working or self-employed in another EEA state

7.9 What is the name of the EEA state in which the relevant EEA national is now active as a

worker or self-employed person?

7.10 What is the relevant EEA national doing in the EEA state named above?

Worker Self-employed

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7.11 When did the relevant EEA national start work/self-employment in the EEA state?

7.12 Give details of the relevant EEA national’s employment or self-employment in the EEA

state below:

Name and address of

employer or business

Job title or position

held or type of

business

Number of

hours normally

worked each

week

Salary or

wage*

Start date of

employment or

self-employment

*Give the gure before deductions for tax, national insurance and other regular deductions.

7.13 If you have any other information to give about the relevant EEA national’s activity in the

EEA state, use the box below:

7.14 Does the relevant EEA national continue to own or rent property for his or her own use in

the UK?

Yes No

If yes, and the address is dierent to the one given in section 1.15 or 2.16, what is that address?

Postcode

7.15 How often does the relevant EEA national return to their address in the UK?

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7.16 Complete the table below with details of all absences from the EEA state mentioned

above by the relevant EEA national. Continue on a separate sheet if necessary:

Country or countries visited Date of

departure

Date of return Number of

days*

* Enter whole days’ absences only. Do not include the day you/they left or returned to the EEA

state. For example, if you/they were absent from the EEA state between 1 January 2014 and 31

January 2014, enter 29 days (2 January to 30 January inclusive).

Now go to section 9.

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Section 8 - Retained right of residence

Complete this section if you previously had a right of residence as the family member of a

relevant EEA national (your ‘sponsor’ named in section 2), you have retained your right of

residence for one of the reasons given below, and you have now completed 5 years’ continuous

residence in the UK (this can include time spent in the UK as the family member of the relevant

EEA national).

Category of retained right

8.1 Tick the relevant box below to indicate the basis on which you claim to have retained your

right of residence.

My sponsor has died and I had lived in the UK for at least one year at the time of his or her

death. (Complete subsections A, E and F.)

My sponsor has died or left the UK and I am, or a family member is, a child of the sponsor (or

of their spouse/civil partner) who is in education. (Complete subsections B and E.)

I am the parent with actual custody of a child mentioned in subsection B. (Complete

subsections B, C and E.)

I, or one of my family members, was the spouse or civil partner of the sponsor and the

marriage or civil partnership has legally ended in divorce, annulment or dissolution.

(Complete subsections D, E and F.)

In all cases, you must submit the relevant evidence listed in section 18 and the guidance notes.

A. Death of sponsor – one year’s residence

8.2 Date the sponsor died: D D M M Y Y Y Y

8.3 How long had you been living in the UK as the family member of the sponsor at the date of

the sponsor’s death?

Years Months

8.4 If other members of your family are applying in this category, list them below and state how

long they had been living in the UK when your sponsor died:

Name of family member How long they had been living in UK

Now go to subsection E.

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B. Sponsor died or left the UK – child or children in education

8.5 If the sponsor has died, date of their death: D D M M Y Y Y Y

8.6 If the sponsor has left the UK, date they left the UK: D D M M Y Y Y Y

Please give details of all children who qualify in this subcategory. If there is more than one child,

make a copy of this page, or continue on a separate sheet, and enclose with your application.

State the number of children applying this category:

When you have completed this subsection, go to subsection E below.

8.7 Full name of the child:

8.8 How is (or was) the child related to the sponsor at the time of his/her death or departure

from the UK?

Child/grandchild of the sponsor

Child/grandchild of the person who was spouse or civil partner of the sponsor when he or she

died or left the UK

8.9 Was the child in education at the time the sponsor died or left the UK?

Yes No

8.10 Is the child currently in education in the UK?

Yes No

8.11 Give further details of the child’s education in the UK in the table below.

Name and address of school(s) or college(s) attended Dates attended (from and to)

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C. Parent with actual custody of a child or children in education

mentioned in subsection B

8.12 Please conrm the name(s) of the child or children of whom you have custody. Continue

on a separate sheet if necessary and enclose with your application.

Full name of child Date of birth Nationality Relationship to

sponsor

Relationship to

you

8.13 How long have you had custody of the relevant child/children?

8.14 What kind of custody is this? Please tick:

Court order By agreement with the sponsor

Other - please state

Now go to subsection E.

D. Marriage or civil partnership ended by divorce, annulment or

dissolution

Note: if you’re the former spouse or civil partner of the sponsor, make sure you complete section

11 with details of the relationship.

(1) General questions

8.15 Please conrm who is the former spouse or civil partner of the EEA national sponsor:

I am the former spouse or civil partner of the sponsor

A member of my family is the former spouse or civil partner of the sponsor

If you have ticked ‘a member of my family’, give their details below:

Full name

Date of birth

D D M M Y Y Y Y

Nationality

Relationship to you

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8.16 Date of the relevant marriage or civil partnership: D D M M Y Y Y Y

8.17 Date legal proceedings began to end the marriage or civil partnership (that is, the date the

divorce petition, nullity petition, dissolution petition, or overseas equivalent, was led):

D D M M Y Y Y Y

8.18 Date the marriage or civil partnership was legally ended (that is, the date the decree

absolute, nal dissolution order, or overseas equivalent, was issued):

D D M M Y Y Y Y

8.19 Were you living in the UK at the date of divorce, annulment or dissolution?

Yes No

8.20 Was your sponsor present in the UK at the date of divorce, annulment or dissolution?

Yes No

8.21 If no, where were they and why? (For example, had they left the UK permanently or were

they away on business or holiday?)

8.22 How long had your sponsor been living in the UK at the date of divorce, annulment or

dissolution?

8.23 How long had you (or the family member named in question 8.15, if you are not the former

spouse/civil partner) been living in the UK at the date of divorce, annulment or dissolution?

8.24 Is the sponsor still living in the UK?

Yes No Don’t know

If no, when did they leave the UK? D D M M Y Y Y Y

8.25 Please tick which of the following applies to you (tick more than one box if relevant):

The marriage or civil partnership referred to above lasted for at least 3 years before legal

proceedings began to end it.

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The parties to the marriage or civil partnership (that is, you, or the family member referred to

in question 8.15, and the relevant EEA national sponsor) lived in the UK for at least one year

while they were still married or in a civil partnership .

If you have ticked the 2 boxes immediately above, you can go straight to subsection E below.

However, you may wish to complete the remaining questions in this subsection if you feel they

are relevant to your circumstances.

I have/the person named in 8.15 has custody of a child of the sponsor. Answer the questions

under (2) below.

I have/the person named in 8.15 has access rights in the UK to a child of the sponsor and the

child is aged under 18. Answer the questions under (3) below.

I, or a member of my family, was the victim of domestic violence while the marriage or

civil partnership referred to above was subsisting, or there are other particularly dicult

circumstances which justify retaining the right of residence. Complete subsection (4) below.

(2) Custody of a child of the sponsor

8.26 Details of the relevant child(ren):

Full name of the child Date of birth Nationality

8.27 Who has custody of the child(ren)?

I do The person named in 8.15 does Someone else does

If ’someone else’, give their details below:

Full name Date of birth Nationality Relationship to child

8.28 What kind of custody is this?

Court order By agreement with the sponsor

Other - please state

8.29 How long have you/they had custody of the child/children?

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(3) Access rights to a child aged under 18 of the sponsor

8.30 Details of the relevant child(ren):

Full name of the child Date of birth Nationality

8.31 Who has access rights to the child?

I do The person named in 8.15 does Someone else does

If ’someone else’, give their details below:

Full name Date of birth Nationality Relationship to child

8.32 Has a court ordered that access must take place in the UK?

Yes No

8.33 How long have you/your family member had these access rights?

Note: you must include the relevant court order with your application.

(4) Domestic violence or particularly dicult circumstances

8.34 If you were, or a family member was, the victim of domestic violence while the marriage

or civil partnership was subsisting, or there are any other particularly compelling circumstances

which you feel justify your retaining your right of residence, please give details below. Continue

on a separate sheet if necessary. You must also provide relevant evidence – see section 18 and

the guidance notes.

Now go to subsection E (below).

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E. Your sponsor’s status in the UK at the relevant date

8.35 Please indicate below your sponsor’s status on the date they died, left the UK, or when

your (or your family member’s) marriage/civil partnership legally ended (‘the relevant date’).

Permanent right of residence

Qualied person (i.e. worker (including retained worker status), self-employed (including

retained self-employed status), self-sucient, student, jobseeker).

You must give details of your sponsor’s activity in the UK while you were still their family member

– see section 9.

Now go to subsection F below.

F. Your status in the UK

You do not need to complete this subsection if you’re applying under category B (child in

education, sponsor has died or left the UK) or C (parent with custody of such a child).

You must provide this information if you’re applying under category A (death of sponsor, one

year’s residence) or D (marriage/civil partnership ended in divorce, annulment or dissolution).

8.36 Complete the table below with information about your activity in the UK since your

sponsor died, left the UK, or their marriage/civil partnership ended.

Activity From (date) To (date)

Working for an employer

Retained worker status - temporary incapacity

Retained worker status - involuntarily unemployed and

looking for work

Retained worker status - unemployed and doing vocational

training

Self-employed

Retained self-employed status - temporary incapacity

Self-sucient

Family member of a non-EEA national in one of the above

categories

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8.37 If you have indicated that you are, or have been, a family member of a non-EEA national

who is/has been working, self-employed or self-sucient, please give their details below:

Full name

Date of birth

D D M M Y Y Y Y

Nationality

Relationship to you

Employment

8.38 If you have (or your non-EEA family member has) been working, give details below:

Name and address of employer Start date of

employment

End date of

employment (if

applicable)

Self-employment

8.39 If you have (or your non-EEA family member has) been self-employed, give details below:

Name and address of business Type of business Date started

trading

Date stopped

trading (if

applicable)

Self-suciency

If you are or have been (or your non-EEA family member is or has been) self-sucient, answer

the questions below.

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Financial resources

8.40 Please indicate your/your family member’s nancial resources. This could include savings,

investments, income from a pension, income from a family member’s lawful employment or self-

employment, and so on. Continue on a separate sheet if necessary.

Source of income How much it is How often you/they

receive it

Comprehensive sickness insurance

8.41 Give details of what form of comprehensive sickness insurance you have (or your non-

EEA family member has) held.

Type of insurance Period(s) held (from and to)

European Health Insurance Card (EHIC) issued by an EEA

member state other than the UK (formerly form E111)

Form S1 (formerly E106, E109 or E121)

Form S2 (formerly E112)

Form S3

Private health insurance plan

Temporary incapacity

8.42 If you are or have been (or your non-EEA family member is or has been) temporarily

unable to work or pursue self-employed activity due to an illness or accident, give details below:

Nature of the illness or accident

How long the incapacity to work lasted or is expected to last:

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Vocational training

8.43 If you have (or your non-EEA family member has) been doing vocational training after

becoming unemployed, give details below:

Name and address of training provider Title of course and

qualication (if

relevant)

Start date End date

8.44 If you/your family member left your/their previous employment voluntarily, is/was the

training related to your/their previous work?

Yes No Not applicable

If yes, how?

Looking for work

If you have (or your non-EEA family member has) been looking for work after becoming

involuntarily unemployed, answer the questions below

8.45 Reason previous employment ended:

8.46 Did you/your non-EEA family member register with the relevant employment oce

(Jobcentre Plus in England, Wales or Scotland, or the Jobs and Benets Oce or Social Security

Oce in Northern Ireland)?

Yes No

If yes, date(s) you/your non-EEA family member registered:

Now go to section 9 to give details of your (former) sponsor’s activity in the UK.

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Section 9 - Relevant EEA national’s activity in the UK

Complete this section with details of the relevant EEA national’s activity in the UK as a qualied

person (also known as ‘exercising Treaty rights’).

‘Relevant EEA national’ means the EEA national who is or has been a qualied person. If you

(the person named in section 1) are not the relevant EEA national, you should complete this

section with details of what your EEA national sponsor (named in section 2 of this form) has

been doing.

‘Qualied person’ means an EEA national who is in the UK as a worker, self-employed person,

self-sucient person, student, or jobseeker. It also includes periods when you/they were

temporarily unable to work due to illness or accident, involuntarily unemployed and looking for

work, or unemployed and doing vocational training.

9.1 If you’re applying as the family member or extended family member of the relevant EEA

national named in section 2, or because you have retained your right of residence, does the

relevant EEA national have a document certifying permanent residence?

Yes - go to 9.2

No - go to subsection A then subsection B (if relevant)

Not applicable - go to subsection A then subsection B (if relevant)

9.2 If you have answered yes to question 9.1, give details of the document below

Date of issue: D D M M Y Y Y Y

Document reference number:

9.3 Are you enclosing the document with your application?

Yes No

If you have answered yes to question 9.3, you do not have to complete the rest of this section –

go straight to section 16 instead. However, we reserve the right to ask you for more information if

necessary.

If you have answered no, complete subsection A with details of your/the relevant EEA national’s

activity in the UK.

If the relevant EEA national is or was an accession state national who worked for an employer

during the accession period (see subsection B for denitions), you should also complete

subsection B.

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A. Details of the relevant EEA national’s activity

9.4 Complete the table below with details of the relevant EEA national’s (your or your

sponsor’s) activity in the UK. Complete in chronological order, starting from when you/they

entered the UK. For each period, briey indicate what you were/your sponsor was doing.

Continue on a separate sheet if necessary.

Give further details of your/your sponsor’s activity in questions 9.5 to 9.12. For any period

in which you were/your sponsor was not a qualied person, or if you wish to give any further

information, give details at 9.13.

(1) Summary of the relevant EEA national’s activity

From (date) To (date) What the EEA national was doing (e.g. working, self-employed,

self-sucient, studying, looking for work, retired, incapacitated,

family member only, etc)

(2) Employment

9.5 For any period in which you were (or your sponsor was) working for an employer, please

give details in the table below. If you need more space, make a copy of this table or continue on

a separate sheet and enclose with your application.

Name and address of employer Start date of

employment

End date of

employment

Salary/

wage*

Reason for leaving

(if applicable)

* Give the ‘gross’ gure before deductions for tax, national insurance, etc. Say whether per

week, month or year.

Note: if you are/your sponsor is a (former) accession state worker, you must also complete

subsection B.

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(3) Self-employment

9.6 For any period in which you were, or your sponsor was, self-employed, please give details

below. Continue on a separate sheet if necessary and enclose with your application.

Name and address of business Type of business Date started

trading

Date stopped

trading (if

applicable)

(4) Temporary incapacity

9.7 If, during the relevant qualifying period, you were/your sponsor was temporarily unable to

work or pursue self-employed activity due to an illness or accident, please give details below:

Nature of the illness or accident:

Period(s) during which you/they were unable to work:

(5) Study or vocational training

9.8 For any period in which you were, or your sponsor was, a student or doing vocational

training, please give details in the table below. Continue on a separate sheet if necessary and

enclose with your application.

Name and address of school,

college, university, or training

provider

Title of course and

qualication

Start date End date

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(6) Study or self-suciency – nancial resources

9.9 For any period in which you were, or your sponsor was, a student or self-sucient person,

please state what nancial resources were available to you/them. Indicate the source of the

income (for example, own savings, scholarship or bursary, income from lawful employment or

self-employment, income from rental property, money from a friend or relative, etc), how much

you/they received and (where relevant) how often you/they received it (for example, every week,

month, year). Continue on a separate sheet if necessary.

Source of income How much you/

they receive(d)

How often you/they

receive(d) it

9.10 If you have any other relevant information about your/your sponsor’s nancial resources,

use the box below. Continue on a separate sheet if necessary.

(7) Study or self-suciency – comprehensive sickness insurance

9.11 For any period in which you were, or your sponsor was, a student or self-sucient person,

indicate below how you/they met the requirement to hold comprehensive sickness insurance

cover (the insurance must also cover family members in the UK).

Type of insurance Period(s) held (from and to)

European Health Insurance Card (EHIC) issued by an

EEA member state other than the UK (formerly form

E111)

Form S1 (formerly E106, E109 or E121)

Form S2 (formerly E112)

Form S3

Private health insurance plan

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(8) Looking for work (jobseeker or retained status worker)

9.12 If you were/your sponsor was in the UK looking for work during the relevant qualifying

period, were you/was your sponsor registered as a jobseeker with the relevant employment

oce (Jobcentre Plus in England, Scotland and Wales; the Jobs and Benets Oce or Social

Security Oce in Northern Ireland)? Tick yes even if claiming national insurance credits only.

Yes No

If yes, dates you/they were registered:

(9) Other periods not accounted for above

9.13 If there are any periods not accounted for in the questions above, or if there is any further

information you would like to give to explain how you acquired permanent residence in the UK,

please provide this information in the box below. Continue on a separate sheet if necessary. If

you do not have any further information to add, leave this blank.

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B. Accession state workers

Complete this subsection if you are/were, or your sponsor is/was, a national of one of the

countries listed below (‘accession states’), and you or they were working for an employer during

the relevant ‘accession period’ (dened below). You must show that you/they were registered

or authorised to do the work in question, unless you/they were exempt from that requirement. If

you/they were not exempt, you/they must have worked for an uninterrupted period of 12 months

in accordance with a relevant registration or authorisation document to become exempt.

EU8 nationals

Accession period: 1 May 2004 to 30 April 2009

Relevant scheme: Worker registration scheme (WRS)

Relevant authorisation

documents:

WRS card or certicate, leave granted before 1 May 2004 giving

permission to work

Czech Republic Estonia Hungary Latvia

Lithuania Poland Slovakia Slovenia

EU2 nationals

Accession period: 1 January 2007 to 31 December 2013

Relevant scheme: Worker authorisation arrangements

Relevant authorisation

documents:

Accession worker (‘purple’) card, Seasonal Agricultural Workers

Scheme (SAWS) card, ‘yellow’ registration certicate issued to

students, ‘blue’ (exempt) registration certicate, leave granted before

1 January 2007 giving permission to work

Bulgaria Romania

EU1 nationals

Accession period: 1 July 2013 to -

Relevant scheme: worker authorisation arrangements

Relevant authorisation

documents:

Worker authorisation (‘purple’) registration certicate, ‘yellow’

registration certicate issued to students, ‘blue’ (exempt) registration

certicate, leave granted before 1 July 2013 giving permission to

work

Croatia

Answer questions 9.14 to 9.18 below.

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9.14 If you or your sponsor worked for an employer during the relevant accession period,

please complete the table below with details of any worker registration, worker authorisation, or

other documents you/they held giving you permission to work. Continue on a separate sheet if

necessary and enclose with your application.

Type of document* Reference

number

Date of

application

Date of

issue

Name of employer or

category of employment

authorised

* For example, WRS card/certicate, accession worker card, SAWS card, worker authorisation

registration certicate, yellow registration certicate (student), etc – see previous page for

relevant documents.

9.15 Did you/your sponsor work for an uninterrupted period of 12 months in accordance with

one or more of the documents mentioned in the table above?

Yes No

If yes, when did you/your sponsor complete this 12-month

period?

D D M M Y Y Y Y

9.16 If, at any point during the accession period, you/your sponsor worked without holding one

of the documents listed in the table above, why was this?

Exempt or not otherwise required to register/obtain authorisation – go to 9.17

Worked without permission – go to 9.18

9.17 If you were/your sponsor was exempt or not required to register or obtain authorisation,

please explain why below – e.g. you had leave which did not restrict your right to work, were the

family member of an EEA national qualied person, spouse/civil partner of a British citizen, etc.

You must also provide relevant evidence – see section 18 and the guidance notes.

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9.18 If you/your sponsor worked without permission at any time during the accession period

(and were not exempt), give details below. Continue on a separate sheet if necessary.

Name of employer Date unauthorised

work started

Date unauthorised

work ended

Now go to—

• Section 11 if you (or anyone applying with you) are or were the spouse, civil partner or durable

partner of the sponsor named in section 2

• Section 12 if you (or anyone applying with you) are or were the descendant (child, grandchild

aged under 21) of the sponsor named in section 2, or of their spouse/civil partner

• Section 13 if you (or anyone applying with you) are or were the dependent child, grandchild,

parent or grandparent of the sponsor named in section 2, or of their spouse/civil partner

• Section 14 if you (or anyone applying with you) are the dependent relative (extended family

member) of the sponsor named in section 2, or a member of their household

• Section 15 if you (or anyone applying with you) are the relative (extended family member) of

the sponsor named in section 2 and you strictly require their personal care on serious health

grounds

• Section 16 in all other cases

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Section 10 - Family member of a British citizen

(‘Surinder Singh’ route)

Complete this section if you’re applying for a document certifying permanent residence or

permanent residence card because you’ve lived in the UK for a continuous period of ve years

as the family member of a British citizen, and that British citizen exercised free movement rights

as a worker or self-employed person in an EEA Member State other than the UK. This is also

known as the ‘Surinder Singh’ route.

10.1 Tick which of the following applies and complete the relevant subsections as directed

I have, or was last issued with, a registration certicate or residence card, or entered the UK

with a valid EEA family permit, as the family member of the relevant British citizen, and that

document has not since been revoked or cancelled.

Complete subsections A and B. Make sure you have also given details of your previous

document in section 5.

I have not previously been issued with a registration certicate, residence card, or an EEA

family permit under the Surinder Singh route, but I had completed 5 years’ continuous

residence in the UK as the family member of the relevant British citizen before 1 January

2014.

Complete subsections A and B below.

I have not previously been issued with documentation under the Surinder Singh route but

I completed 5 years’ continuous residence in the UK as the family member of the relevant

British citizen ending on or after 1 January 2014. Complete subsections A, B and C below.

A. Details of the British citizen’s activity in the EEA state

10.2 What is the EEA state in which your British citizen family member exercised their free

movement rights?

10.3 What was the British citizen doing in the EEA state?

Working Self-employed

10.4 Date the British citizen starting working or self-employment in the EEA state:

D D M M Y Y Y Y

10.5 Date the British citizen stopped working or self-employment in the EEA state:

D D M M Y Y Y Y

Please provide further information about the British citizen’s work, self-employment or other

activity in the EEA state below.

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(1) Employment

10.6 Please list all of the British citizen’s employment in the EEA state, starting with the most

recent. Continue on a separate sheet if necessary.

Name and address of

employer

Job title/

position held

Number

of hours

normally

worked

each week

Salary or

wage*

Start and end date of

employment

* Please give the ‘gross’ gure (i.e. before deductions for tax, national insurance (or equivalent)

and any other deductions). Say if the amount is per week, month or year.

(2) Self-employment

10.7 Name of the British citizen’s business:

10.8 Address of the business:

Postcode

10.9 Website address of business (if applicable):

10.10 Type of business (for example, what product(s) the business made or sold, what services

they provided, etc):

Note: you must provide evidence of the British citizen’s activity in the EEA state. See section 18

and the guidance notes for details.

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(3) Other activity

10.11 Use the box below to explain what the British citizen was doing during any period

when they were not working or self-employed in the EEA state, or to give any further relevant

information about their work or self-employment not mentioned above. This could include, for

example, periods when they were unable to work due to an illness or accident, or they were

involuntarily unemployed and looking for work or doing vocational training.

Please also provide any relevant evidence (for example, proof of receipt of state benets,

proof incapacity, etc) – see section 18 and the guidance notes. Continue on a separate sheet if

necessary.

B. Residence in the EEA Member State

10.12 Please give details of where you, the British citizen, and any other family members (if

applicable) lived while the British citizen was working or self-employed in the EEA state. Start

with the most recent address and continue on a separate sheet if necessary. You must also

provide relevant evidence – for example, tenancy agreements, mortgage statements, utility bills,

etc. See section 18 and guidance notes for details.

Address Who lived there

(you, the British

citizen, any

other family

members)

Dates lived

there (from/to)

Ownership of property - please

state whether owned, rented,

provided by employer, etc.

10.13 Date the British citizen returned

to live in the UK:

D D M M Y Y Y Y

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10.14 If you or your family members lived with the British citizen in the relevant EEA state, date

you/they returned to live in the UK. If not applicable, write N/A

You: D D M M Y Y Y Y

Other family members:

C. Integration in the EEA Member State

10.15 Use the box below to provide any other information which you feel demonstrates that

the relevant British citizen transferred the centre of his or her life to the EEA Member State, and

provide supporting evidence where possible. This could include things like:

• details of nancial commitments in the EEA state (for example, mortgage, rental agreement,

bank account, investments)

• evidence of learning or speaking the language of the EEA state (e.g. qualications, evidence

of attendance at language classes)

• if you had any children or grandchildren living with you in the EEA state, details of any

nursery/school/college/university they attended

• membership of any social groups or sports clubs

• details of any community activities undertaken in the EEA state

• any other relevant information

Now go to—

• Section 11 if you’re the spouse or civil partner of the British citizen

• Section 12 if you’re the descendant (child or grandchild aged under 21) of the British citizen

• Section 13 if you’re a dependent family member (child or grandchild aged over 21, parent or

grandparent) of the British citizen

Then go to section 17 (personal history).

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Section 11 - Spouse, civil partner or durable partner

of the sponsor

Complete this section if you’re applying for a document certifying permanent residence or

permanent residence card because you are (or were) the spouse, civil partner, or durable partner

of the person named in section 2 of this form (your ‘sponsor’).

11.1 Please tick which applies to you:

I’m currently the spouse or civil partner of the sponsor. Complete all subsections (A to E).

I was the spouse or civil partner of the (EEA national) sponsor and I have retained my right of

residence following divorce, annulment or dissolution of the marriage/civil partnership, or my

spouse/civil partner has died. Complete subsections A to D.

I’m currently the unmarried or same-sex partner of the relevant EEA national, I’m in a durable

(lasting) relationship with them, and I’ve held valid residence documentation as their partner

throughout the relevant qualifying period. Complete subsections A, B, C, and E.

I was previously the durable partner of the relevant EEA national and held valid residence

documentation as their partner, and I’m now married to or in a civil partnership with them.

Complete all subsections (A to E).

A. How and when your relationship began

11.2 When and where did you rst meet your sponsor?

11.3 When did your relationship begin?

11.4 Are you and your sponsor related outside of your marriage/civil partnership/relationship?

Yes No

If yes, how are you related?

B. Contact with your sponsor and living arrangements

11.5 Do you and your sponsor currently live together?

Yes answer questions 11.6 to 11.8

No answer questions 11.9 to 11.13

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If you’re currently living together:

11.6 When did you start living together?

11.7 Were you in a relationship with each other when you started living together?

Yes No

11.8 If you have lived with your sponsor at an address other than the address given in section 1

of this form during the relevant qualifying period, please list them below. Continue on a separate

sheet if necessary.

Postcode

From D D M M Y Y Y Y To D D M M Y Y Y Y

If you’re not currently living together:

11.9 Why do you not currently live with your sponsor?

11.10 Have you ever lived with your sponsor within or outside the UK?

Yes No

If yes, please provide details of when and where you previously lived with your sponsor

11.11 How often do you see (meet) your sponsor?

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11.12 When did you last see your sponsor?

11.13 How do you keep in touch with your sponsor?

C. Children

11.14 Do you and your sponsor have any children together?

Yes No

11.15 Do you have any children of whom your sponsor is not the parent (such as, from a

previous or other relationship)?

Yes No

11.16 Does your sponsor have any children living in the UK of whom you are not the parent?

Yes No

If you have answered no to questions 11.14, 11.15 and 11.16, go to subsection D (if you’re the

current or former spouse of the sponsor), or subsection E (if you’re the durable partner of the

sponsor).

11.17 If you have answered yes to questions 11.14, 11.15 or 11.16, have you included the

child/children in this application?

Yes go to subsection D (spouse/civil partner) or E (durable partner)

No if any of the children mentioned in 11.14, 11.15 or 11.16 are not included in your

application, please explain why not below:

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D. Marriage or civil partnership

11.18 When did you decide to marry or form a civil partnership with your sponsor?

11.19 Date of your marriage or civil partnership

D D M M Y Y Y Y

11.20 Where (in what town/city and country) did your wedding or civil partnership ceremony

take place?

11.21 Were you and your sponsor both present at the ceremony? Please tick:

Yes No

If no, please explain why not and where you were/your sponsor was at the relevant time:

E. Other relationships

11.22 Do you or your sponsor currently have another spouse or civil partner, or an unmarried or

a same-sex partner with whom you or they are in a durable relationship?

Yes No

11.23 Have you or your sponsor been married, in a civil partnership, or in a long-term

relationship before your current relationship?

Yes No

11.24 If you have answered yes to either of the above questions, please give details of all other

current or previous marriages/civil partnerships/relationships in the box below. Details should

include name and nationality of former partner, date and place of any marriages and divorce,

annulment or dissolution, how long the relationship lasted, date of death of former partner (if

applicable), and any other relevant details.

Now go to -

• Section 17 if your sponsor is a British citizen

• Section 16 in all other cases

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Section 12 - Descendant (child or grandchild) aged

under 21

Complete this section if you are (or anyone included in this application is) applying as a

descendant aged under 21.

‘Descendant’ means the child or (great-) grandchild of the sponsor, or of the sponsor’s spouse or

civil partner.

Note: if the sponsor has only had a right to reside as a student, you can only include dependent

children in this section. Grandchildren of students must qualify as extended family members and

should complete section 14 or 15 instead.

Descendants aged 21 or over must complete section 13 of this form.

If more than one person is applying in this category, make and complete an additional copy of

this section for each descendant aged under 21 and enclose it with your application. Clearly

write the name of the descendant on each copy.

Number of descendants aged under 21

Name of descendant

12.1 Please give details of your parents, as recorded on your birth certicate, legal adoption

order, or UK parental order.

Mother/parent 1 Father/parent 2

Full name

Date of birth

Nationality

12.2 Do you currently live with both parents named in question 12.1?

Yes No

12.3 If you have answered no to question 12.2, and you are under the age of 18, please

explain who you normally live with and the reasons for this below. You must also provide relevant

supporting evidence (see section 18 and the guidance notes).

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12.4 Are you currently working (including self-employment) in the UK?

Yes No

If yes, please give details below:

Name and address of employer or

business

Number of

hours normally

worked each

week

Wages per week/

month* (please

specify)

Date this

employment started

* Give the gure before any deductions for tax, national insurance or other regular deductions.

12.5 Are you currently in education (including school, college, university, or vocational

training)?

Yes No

If yes, please give details below. Continue on a separate sheet if necessary:

Name and address of educational

establishment

Name of course

or qualication

Course start date Course end date

Now go to -

• Section 17 if your sponsor is a British citizen

• Section 16 in all other cases

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Section 13 - Dependent family member (child,

grandchild, parent, grandparent)

Complete this section if you are (or anyone included in this application is) applying for a

document certifying permanent residence or a permanent residence card as the dependent

family member of the sponsor named in section 2. You must be either the:

• dependent child or (great-)grandchild aged 21 or over of the sponsor (or of their spouse or

civil partner)

• dependent parent or (great-)grandparent of the sponsor (or of their spouse or civil partner)

Note: if your sponsor is an EEA national who only has a right to reside as a student, and you’re

their grandchild, parent or grandparent, you must qualify as an ‘extended’ family member and

should complete section 14 or 15 instead.

In this section—

‘Sponsor’ means the person who gives you nancial support. This must be the relevant EEA

national or British citizen named in section 2, or their spouse or civil partner, or both.

‘Dependent’ means that you need the nancial help of your sponsor to meet your essential

needs.

If more than one person is applying in this category, make and complete an additional copy of

this section for each dependent family member and enclose it with your application. Clearly write

the name of the dependant on each copy.

Number of dependent family members:

Name of dependant:

Your sponsor

13.1 Is your sponsor:

(a) The EEA national or British citizen named in section 2

(b) The EEA national’s or British citizen’s spouse or civil partner

If you have ticked (b) or (c), please give details of the sponsor’s spouse or civil partner below:

Full name:

Date of birth: D D M M Y Y Y Y

Nationality:

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13.2 How long have you been dependent on your sponsor?

Your income

13.3 Does your sponsor regularly give you money?

Yes No

If yes, please say how much and how often:

13.4 Do you receive nancial assistance from any other relative or friend?

Yes No

If yes, give details (including how much and how often) below:

13.5 Are you currently working (including self-employment) in the UK?

Yes No

If yes, please give details below:

Name and address of employer or

business

Number of

hours normally

worked each

week

Wages per week/

month* (please

specify)

Date this

employment started

* Give the gure before any deductions for tax, national insurance or other regular deductions.

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13.6 Please give details in the table below of any other regular source of income or capital

you have, in the UK or overseas. This could include, for example, a company or state pension,

income from rental property, savings, investments, and so on. Continue on a separate sheet if

necessary.

Source of income How much you

receive

How often you

receive it

Accommodation

13.7 Do you currently live with your sponsor?

Yes No

13.8 Do you pay any rent, mortgage or other payment for this accommodation?

Yes No

If yes, give details in question 13.9.

Outgoings and expenditure

13.9 Please complete the table below with details of your regular outgoings and expenditure.

This could include things like rent/mortgage, gas, electricity, or water bills, medical bills,

insurance, etc. If your sponsor or another relative or a friend helps you with these, please give

details in the third column.

If you need to give more details, you can use the box at the end of this section or provide them

on a separate sheet if necessary.

Outgoing Amount per month Who pays (e.g. you, your sponsor, a

relative/friend)

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13.10 Please give any other relevant information about how you are dependent. This could

include any further information about your nancial circumstances or details of any emotional or

physical support you receive from your sponsor. If you have no further information to add, please

leave this blank.

Now go to -

• Section 17 if your sponsor is a British citizen

• Section 16 in all other cases

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Section 14 - Extended family member (relative) who

is dependent on the EEA national or is a member of

their household

Complete this section if you are (or anyone included in this application is) applying for a

document certifying permanent residence or permanent residence card because you’re a relative

of the relevant EEA national, or of their spouse or civil partner, and you:

• were dependent on the EEA national or were a member of their household before you came

to the UK and

• since entering the UK, have continued to be dependent on the EEA national or be a member

of their household

Note: you must have held valid residence documentation (registration certicate, residence

card or EEA family permit) as the relevant EEA national’s extended family member throughout

the relevant qualifying period. If you have not, you will not qualify for permanent residence. If

you wish to apply for a registration certicate or residence card, you should complete form

EEA(EFM) instead.

In the rest of this section, ‘sponsor’ means the relevant EEA national named in section 2 of this

application form and of whom you are a relative.

If more than one person is applying in this category, make and complete an additional copy of

this section for each dependent relative and enclose it with your application. Clearly write the

name of the relative on each copy.

Number of dependent relatives

Name of relative

Your current status

14.1 Are you currently dependent on your sponsor or are you a member of your sponsor’s

household in the UK ? Tick more than one if relevant.

Yes, dependent Yes, member of their household

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Income

14.2 Do you regularly receive money from your sponsor?

Yes No

If yes, please say how much, how often and for how long:

14.3 Do you regularly receive money from any other relative or friend?

Yes No

If yes, please say how much, how often and for how long:

14.4 Please give details in the table below of any other regular source of income or capital

you have, from the UK or elsewhere. This could include, for example, income from employment

or self-employment, a company or state pension, state benets, income from rental property,

savings, investments, and so on. Continue on a separate sheet if necessary.

Source of income How much you

receive

How often you receive

Accommodation

14.5 Do you currently live with your sponsor?

Yes No

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14.6 If you have answered yes to 14.5, is this property owned or rented by the EEA national,

or is the EEA national the person mainly responsible for paying any rent, mortgage or other

payment?

Yes No

14.7 Who else lives with you (apart from your sponsor, if applicable)? Continue on a separate

sheet if necessary.

Name Relationship to you

Outgoings and expenditure

14.8 Please complete the table below with details of your regular outgoings and expenditure.

This could include things like rent/mortgage, gas, electricity, or water bills, medical bills,

insurance, etc. If the EEA national or another relative or a friend helps you with these, please

give details in the third column. If you need to give more details, you can give these in the box at

the end of this section or provide them on a separate sheet and enclose with the application.

Outgoing Amount per month Who pays (e.g. you, your sponsor, a

relative/friend)

14.9 Please give any other relevant information in the box below to show how you are

dependent on your sponsor. This could include:

• further information about your nancial circumstances before or after coming to the UK

• details of any emotional or physical support you receive, or have received, from the EEA

national

• your family circumstances in your home country

• details of any compelling or compassionate circumstances which would make it dicult for

you to live in your home country without the EEA national’s support

• any other relevant information

Continue on a separate sheet if necessary and enclose it with the application.

Now go to section 16.

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Section 15 - Extended family member (relative) who

strictly requires the personal care of the EEA national,

or of their spouse or civil partner, on serious health

grounds

Complete this section if you are (or anyone included in this application is) applying for a

document certifying permanent residence or permanent residence card because you’re a relative

of the relevant EEA national named in section 2, or of their spouse or civil partner, and you

strictly require their personal care on serious health grounds.

Note: you must have held valid residence documentation (registration certicate, residence

card or EEA family permit) as the relevant EEA national’s extended family member throughout

the relevant qualifying period. If you have not, you will not qualify for permanent residence. If

you wish to apply for a registration certicate or residence card, you should complete form

EEA(EFM) instead.

If more than one person is applying in this category, make and complete an additional copy of

this section for each relative who requires care and enclose it with your application. Clearly write

the name of the relative on each copy.

Number of relatives requiring care

Name of relative

15.1 What is the nature of your health condition(s)?

15.2 How long have you had this (these) health condition(s)?

15.3 How long is (are) the health condition(s) expected to last?

15.4 Are you able to care for yourself on a daily basis – that is, undertake daily tasks, such

as washing and dressing yourself, or preparing food for yourself, without the help or support of

anyone else?

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Yes No

If no, please say which daily tasks you have diculty with:

15.5 Who currently provides you with the majority of your care?

a) The relevant EEA national

b) The EEA national’s spouse or civil partner

c) Both

d) Someone else

15.6 If you have ticked (b), (c) or (d), please give the name, nationality and date of birth of the

other person. If you have ticked (d), please also say what their relationship is to you.

Full name

Date of birth

Nationality

Relationship to you

15.7 Please describe the care they provide you with and how often:

15.8 Do you receive any care from any other person or organisation (for example, social

services) not mentioned in questions 15.5 and 15.6 above?

Yes No

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If yes, please provide details below:

15.9 Before the EEA national (or their spouse or civil partner) started caring for you, did anyone

else (or any organisation, such as social services) provide care?

Yes No

If yes, please give details below and explain why the arrangement stopped (if it stopped):

15.10 Are you currently doing any work, paid or unpaid, employed or self-employed, in the UK?

Yes No

If yes, please give details below:

Name and address of employer or

business

Number of hours

normally worked

each week

Wages per

week/month*

(please specify)

Date this

employment

started

*Give the gure before any deductions for tax, national insurance or other regular deductions.

15.11 If you wish to provide any further information about your circumstances, please use the

box below. Continue on a separate if necessary and enclose it with the application.

Now go to section 16.

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Section 16 - Public funds (state benets)

This section asks for information about any public funds or state benets (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 do not have to complete this if you’re the family member of a British citizen and

applying in the ‘Surinder Singh’ category (see section 10).

16.1 Are you/is your sponsor claiming, or have you/has your sponsor claimed, since living in

the UK, any of the public funds or state benets listed in the table below?

Attendance allowance Disability living allowance Personal independence

payment

Carers allowance Housing and homelessness

assistance

Severe disablement

allowance

Child benet Housing benet Social fund payment

Child tax credit Income-based jobseeker’s

allowance

State pension credit

Council tax benet Income related employment &

support allowance – ESA (IR)

Universal credit

Council tax reduction Income support Working tax credit

Yes No

16.2 If you have answered yes to question 16.1, please complete the table below to show the

amount you/your sponsor receive(s), or received, each week/month and for how long the benet

has been paid. Continue on a separate sheet if necessary.

Benet Who receives it Amount you/

they receive

each week/

month (please

specify

frequency)

Date you/

they started

receiving this

benet

Date you/

they stopped

receiving this

benet (if you/

they no longer

receive it)

Now go to section 17.

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Section 17 - Personal history

This section asks you about any criminal convictions you (or any family members who are

applying with 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 oence 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.

17.1 Have you (or any family members who are applying with you) been convicted of any

criminal oence in the UK or any other country?

Yes - continue below No - go to question 17.2

Please give details below for each criminal conviction, starting with the most recent one. If you

(or any family members who are applying with you) have received more than one conviction,

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 trac oences but not xed penalty notices (such as

speeding or parking tickets) unless they were part of a sentence of the court. This includes all

drink-driving oences.

Criminal conviction 1

Name under which you were convicted:

Country where convicted:

Nature of the oence:

Sentence given:

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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

17.2 Do you (or any family members who are applying with you) have any civil judgments

against you or any civil penalty under the UK immigration acts?

Yes continue below No go to question 17.3

Give details for each civil judgment or any civil penalty under the UK immigration acts, starting

with the most recent one.

If you (or any family members who are applying with you) have received more than one 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:

You must answer the following questions even if you have answered that you (or any family

members who are applying with you) have not been convicted of any criminal oence in the UK

or any other country.

For help in answering these questions, please see the denitions at the end of this section.

Provide more details on a separate sheet of paper if necessary and submit it with your

application.

17.3 Have you (or any family members who are applying with you) ever been charged or

indicted in any country with a criminal oence for which you have not yet been tried in court?

Yes Please provide details: No go to question 17.4

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17.4 In either peace or war time, have you (or any family members who are applying with 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 17.5

17.5 Have you (or any family members who are applying with you) ever been involved in,

supported or encouraged terrorist activities in any country?

Yes Please provide details: No go to question 17.6

17.6 Have you (or any family members who are applying with 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 17.7

17.7 Have you (or any family members who are applying with 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 17.8

17.8 Have you (or any family members who are applying with 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 go to question 17.9

17.9 Please state what ties you (or any family members who are applying with you) have with:

• the country where you were born

• any other country whose nationality you hold

• any country where you have lived for more than 5 years

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You should tell us about any family friends, or other connections with that country:

Country Social, cultural or family ties

Denitions

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 denitions 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 Oce (telephone 0870 600

5522). It is the your responsibility to satisfy yourself that you are familiar with the denitions and

can answer the questions accurately.

War crimes

Grave breaches of the Geneva Conventions committed during an armed conict. This includes

an internal armed conict and an international armed conict. The types of acts that may

constitute a war crime include wilful killing, torture, extensive destruction of property not justied

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 conict) as part of a widespread or systematic

attack, directed against any civilian population with knowledge of the attack. This would include

oences 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.

Terrorist activities

Any act committed, or the threat of action, designed to inuence 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 glorication of

terrorism); or is otherwise concerned in terrorism.

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Section 18 - Documents and evidence

Complete this section to indicate what documents you’re submitting with your application.

Please also complete the document checklist on the nal page of this form.

Please note: this section provides only brief guidance on what documents to submit. You

must refer to the full guidance on our website at: www.gov.uk/government/publications/

apply-for-a-document-certifying-permanent-residence-or-permanent-residence-card-form-eea-pr

If you don’t submit sucient evidence to show that you qualify for a document certifying

permanent residence or permanent residence card, we will refuse your application.

Photographs (sections 1-2) – 2 passport-sized photographs of you and each family member

included in your application; and one passport-sized photograph of your sponsor. The photos

must conform to the standards at www.gov.uk/photos-for-passports

Proof of identity and nationality (sections 1-2) – for example, a valid passport, travel

document or national identity card for you, any family members applying with you, and your

sponsor (if applicable).

If you can’t provide any of these documents you must explain why and provide alternative

evidence of your/their identity and nationality.

Proof of relationship to your sponsor (sections 1-2) – for example, birth or adoption

certicates, marriage/civil partnership certicates, etc, clearly showing the relationship

Replace/renew your permanent residence document (section 4) – your previous permanent

residence document (if available) or police lost property report/crime reference number.

Proof of continued residence in the UK if document issued more than 2 years ago.

Previous immigration or residence documents (section 5) – registration certicate, residence

card, biometric residence permit; previous passports, travel documents or national identity

cards; police lost property report or crime reference number for lost/stolen documents

Proof of residence in UK (sections 4-8) or EEA state (section 10) for the relevant period – for

example, utility bills, bank statements, council tax (or equivalent) bills, NHS (or equivalent)

letters, mortgage/tenancy agreements, etc.

Sponsor has died (section 6) – sponsor’s death certicate, proof your sponsor was working

or self-employed before he or she died (see notes for section 9), proof of your/their residence

in the UK before his/her death

You have/sponsor has ceased activity (section 7) – evidence of receipt of pension,

permanent incapacity, or work/self-employment in another EEA state; evidence of previous

work/self-employment and residence in the UK

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Retained right of residence (section 8) –

• death certicate for sponsor (8A or 8B)

• evidence of child’s attendance at school (8B or 8C)

• evidence of custody of or access rights to children (such as court order) (8C or 8D)

• decree absolute or dissolution order (8D)

• evidence of domestic violence – for example, evidence of conviction against sponsor,

medical report, letter from women’s refuge (8D)

• evidence your sponsor had permanent residence or was a qualied person (8E)

• evidence of your status (for example, proof of employment, self-employment, self-

suciency) (8F)

• evidence of your previous residence in the UK as a family member

Your sponsor’s document certifying permanent residence if they have one (9.1)

Evidence of employment (sections 6-10) – for example, employer’s letter, wage slips, bank

statements showing receipt of wages, P60s

Evidence of self-employment (sections 6-10) – for example, tax self-assessment forms, proof

of payment of class 2 or 4 national insurance contributions, invoices for work done, business

accounts, business bank statements, etc

Evidence of temporary or permanent incapacity (sections 7-10) – for example, letter from

doctor or medical report, evidence of sickness-related benets

Evidence of vocational training (sections 8-10) – letter from training provider giving details of

training

Evidence of self-suciency (sections 8-9) – for example, bank statements, building society

pass book, evidence of receipt of pension, etc.

Evidence of study (section 9) – for example, letter from school/college/university, statement

of sucient nancial resources, bank statements, evidence of receipt of scholarship or

bursary, etc.

Evidence of comprehensive sickness insurance for students and self-sucient persons

(sections 8-9) – European Health Insurance Card (not issued by the UK); form S1, S2, or S3;

or evidence of comprehensive private medical insurance.

Note: The denition of comprehensive sickness insurance does not include cash back health

schemes, travel insurance policies or access to the UK’s National Health Service (NHS).

EEA(PR) - Version 03/19

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Evidence of looking for work (sections 8-10) – for example, proof of receipt of job-seeking

benets, letters of invite to interviews, rejection letters from employers, evidence of academic

or professional qualications, etc.

Accession state nationals: proof of authorisation to work (section 9B) – for example, worker

registration cards or certicates, accession worker card, blue or yellow registration certicate,

worker authorisation (purple) registration certicate, passport endorsed with leave to remain,

or proof of exemption

Surinder Singh (section 10):

• evidence of your sponsor’s employment or self-employment in another member state

• evidence of your/your sponsor’s residence in another member state

• evidence your sponsor transferred their centre of life to the other member state – for

example, details of nancial commitments, evidence of family living with them, etc

Marriage/civil partnership/durable relationship (section 11):

• marriage or civil partnership certicate (if applicable)

• proof of living together (such as utility bills, mortgage/tenancy agreements, NHS letters,

etc)

• birth certicates of children you have

• evidence that any previous marriage or civil partnership has legally ended – for example,

divorce certicate

Descendant under 21 (section 12) – birth or adoption certicate(s) for children; if the child is

under 18 and not living with his/her parents, parental order or residence order, or letter from

parent(s) consenting to living arrangements

Evidence of dependency or household membership (sections 13 and 14) – for example,

money transfer receipts, bank statements showing money transfers, evidence of

accommodation provided by sponsor, etc.

Evidence of strictly requiring personal care (section 15) – for example, detailed medical

report from registered medical consultant

Public funds/state benets (section 16) – for example, letter(s) from DWP, HMRC or local

authority giving details of benet(s) or tax credits received, bank statements showing receipt

of relevant benet(s)

Now go to section 19.

EEA(PR) - Version 03/19

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Section 19 - Declarations

You (the applicant) should complete subsection A and your sponsor (named in section 2 of this

form, if relevant) should complete subsection B, unless they are unable to do so.

A. Applicant’s 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 may sign it.

I hereby apply for a document certifying permanent residence / permanent residence card for

myself and any family members included in this application. The information I have given in this

form is complete and is true to the best of my knowledge.

I conrm that the photographs submitted with this form are a true likeness of me and my family

members, as named on the back of each photograph, and that I have had the opportunity to see

the Home Oce photograph guidance.

I conrm 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 Oce.

I understand that all information provided by me to the Home Oce will be treated in condence

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 Oce 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 or my family members have, or my sponsor has, a right of

residence.

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 Oce 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 Oce 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 Oce may also use the information provided by me for training

purposes.

I am aware that it is an oence 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 document certifying permanent

residence or permanent residence card by means which include deception.

I understand that if I am, or anyone included in this application is, informing the Home Oce that

I or they have changed gender, these details may in certain circumstances be shared with other

Home Oce 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 condence 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 unaected.

Signed Date D D M M Y Y Y Y

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B. Sponsor’s declaration

The sponsor named in section 2 of this application form (if applicable) should read the

declaration below and sign it, unless the sponsor is unable to sign it for one of the reasons given

below. It should be signed by your sponsor and not by a representative or other person acting on

your or your sponsor’s behalf. If your sponsor is under 18, their parent or guardian may sign it.

Sponsor is unable to sign because:

They have died They have left the UK

I am unable to contact the sponsor Other (please state):

I conrm that I am the sponsor named in section 2 of this application form and I am the family

member, relative or partner of the applicant (and any family members) named in section 1.

The information the applicant has given in this form is complete and is true to the best of my

knowledge.

I conrm that the photograph submitted with this form is a true likeness of me, as named on the

back of the photograph, and that I have had the opportunity to see the Home Oce photograph

guidance.

I conrm 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 Oce.

I understand that all information provided by me or the applicant to the Home Oce will be

treated in condence 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 Oce

with any information about me which may be relevant for immigration purposes, it may be used

in reaching a decision on the application or on whether I have, or the applicant has, a right of

residence.

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 Oce 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 Oce 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 the application being

refused and in my /the applicant’s prosecution and subsequent removal from the UK.

I understand that the Home Oce may also use the information provided by me or the applicant

for training purposes.

I am aware that it is an oence 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 document certifying permanent

residence or permanent residence card by means which include deception.

EEA(PR) - Version 03/19

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I understand that if I am informing the Home Oce that I have changed my gender, these

details may in certain circumstances be shared with other Home Oce 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 condence 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 unaected.

Signed Date D D M M Y Y Y Y

EEA(PR) - Version 03/19

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Document checklist

Please complete the tables below to help us check that we have received your identity and other

documents and to keep a record of them while they are with us. Continue on a separate sheet if

necessary.

A. Identity documents

Documents How

many?

Passport-sized photographs

Passports

National identity cards

Biometric residence permits (BRPs)

Birth certicates

Marriage/civil partnership certicates

Driving licence (paper or photo)

Deed poll

B. Other documents (please list)

Document How

many?

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