T1 or 5 Dependant Form November 2015

Tier 1 or 5 PBS
Dependant
version 11/2015
Application for a Grant of Leave and

Biometric Immigration Document as a
Tier 1 or 5 Dependant
In accordance with paragraph 34 of the Immigration Rules, this form is
specified for applications made on or after 19 November 2015. Please check
on the website at www.gov.uk/browse/visas-immigration/work-visas that this
is the current form for use on the date that you apply.
You are advised to read the help text and separate guidance notes that
are available to help with this form. Please read them before making your
application. If you do not already have them, you can download them from
our website.
Applications made on this form may be made by post, courier or in person at
one of our Premium Service Centres. To apply in person you must make an
appointment. Details of our Premium Service Centres can be found on our
website:
https://www.gov.uk/ukvi-premium-service-centres
As part of your application you may be required to pay the Immigration
Health Surcharge. Before going any further, you should check www.gov.
uk/healthcare-immigration-application to confirm if an Immigration Health
Surcharge assessment is required as part of your application. You must
complete this before making your application and enter the reference
number in this application.
Please post or courier your application to:
Postal address:
Postal address:
Courier address:
Home Office
Home Office
Home Office
Tier 1 Dependants
Tier 5 Dependants
Tier 1 or 5 Dependants
PO Box 496
PO Box 506
Wearside House
Durham
Durham
Riverside Place
DH99 1WQ
DH99 1WB
Freemans Reach
Durham
DH1 1SL
This form is
specified for
applications
made on or after
19 November
2015
TIER 1 OR 5 DEPENDANT APPLICATION FORM
Intentionally Blank
Tier 1 or 5 Dependant Application Form (Version 11/2015) - page 2 of 35
Section A - Payment Details

A1 Fee Details
Please complete this section in block capitals and black ink. You should complete all questions in
this part of the form that apply to you. It is mandatory to complete Section A. If it is not complete,
the application will be invalid and returned to you.
You should refer to the Payment Guidance Notes which accompany this application form.
Section A - Application Details

A1. Tick appropriate box below. If you do not select a fee then we cannot take a payment and your
application will be rejected as invalid.
Tier 1 - General
1,736
Tier 1 Entrepreneur
1,180
Tier 1 Investor
1,500
Tier 1 Exceptional Talent
562
Tier 1 Exceptional Talent Extension
562
Tier 1 Graduate Entrepreneur standard
456
Tier 5 standard
225
A2 Application Details
You should refer to the Payment Guidance Notes which accompany this application form. Please
complete this section in block capitals and black ink.
A2.1 Correspondence address
Postcode
A2.2
Contact name in the UK if different to that of the dependant.
A2.3
Your full name
A2.4 Your date of birth

Month
Day
Year
A2.5 Main Applicants full name
A2.6 Main Applicants date of birth

Day
Year
Month
A2.7 Please select the method of payment from the list below
Debit or credit card United Kingdom postal order (payable to
go to question A2.9
Home Office) - go to part B
Cheque (payable to Home Office) - go
to question A2.8
Bankers draft - go to
question A2.8
A2.8 Paying by cheque - please give cheque details below

Sort code
Account number
A2.9 Paying by card
Which card are you using for
payment? Please tick a box and
complete A2.10 - A2.14 below.
Visa /
Electron
MasterCard
/Amex
Cheque number
Delta
Maestro/
Solo
A2.10 Name on
card
A2.11 Card
number
A2.12 Card
details
Valid from
A2.13 Cardholders signature
Expiry date
3 digit number Security No - CVV

Issue
(or 4 digit
No.
number for
(where
Amex)
available)
A2.14 Date
Year
Month
Day
If you are producing a double-sided copy of this

application form, please include this page and make
sure it falls on the reverse of the payment details
page in the two-sided copy.
For administrative reasons, it is important that
the rest of the form begins with Section B Your Personal Details facing upwards

You must complete all of the sections and questions in this form that apply to you.
The form will not be valid if it is not fully completed.
There is a separate help text leaflet available with this form. Where a question in this form has
information available in the help text leaflet it will be marked with (ht).
Section B Your personal details

In this section you will be asked to provide information about your personal situation, for example
your name, date of birth and nationality as well as information about any other names you have
used, or other nationalities you have held.
Photographs
For your application to be valid, you must provide two recent identical passport-size photographs of
yourself with your full name written on the back of each one. The photographs must be in the format
specified in the separate photograph guidance, including the mandatory requirements, which can
be found on our website at https://www.gov.uk/photos-for-passports
Please ensure that you place the photographs in a small sealed envelope attached to this part of
the form and without allowing any staples, clips, pins or anything else to mark or damage the
photographs. The photographs will be checked against the images taken when your biometric
features are recorded
I have enclosed the required photographs as outlined above.
B1; What is your name, as given in your passport or travel document? (ht)
Title - please select from the following list:
Mr
Mrs
Miss
Ms
Dr
Other
First name(s) or given name(s):
Last name(s) or family name(s):
B2; What is your gender?
B3; What is your date of birth?
Male
Female
B4; What is your relationship status? (ht)

Married
Dissolved Civil Partnership
Civil Partner
Surviving Civil Partner
Single
Unmarried Partner
Divorced
Separated
Widow/Widower
Separation Order

B5; What village, town or city were you born in?
B6; What is your country of birth?
B7; What is your current nationality? (ht)
B8; If you currently hold or have ever held any other Nationality, please provide details in the
box below: (ht)
What Nationality did you or do you hold?
Date held from:
Date held to:
Please tick to confirm that you are submitting the required

evidence relating to this other Nationality with this application
B9; If you are currently known by or have ever been known by any other name, please
provide details in the box below: (ht)
What name are you or were you known by?
Date of Birth
Dates that you Dates that you
when using
used this name used this name
this name:
from:
to:
Please tick to confirm that you are submitting the required

evidence relating to this other name with this application
B10. Please provide your Immigration Health Surcharge reference number (IHS):
I
Now go to Section C
Section C Details about the PBS main applicant you are dependent on
In this section you will asked questions about the PBS main applicant that you are dependent on.
C1; What is the full name of the PBS main applicant you are dependent on, as stated in their
passport or travel document?
Mr
Mrs
Miss
Ms
Dr
Other
First name(s) or given name(s):
Last name(s) or family name(s):
C2; What is the date of birth of the PBS main applicant you are dependent on, as stated in
their passport or travel document?
D
C3; What is the nationality of the PBS main applicant you are dependent on, as stated in
their passport or travel document?
C4; What is the reference number for the most recent application of the PBS main applicant
you are dependent on? (ht)
C5; Have you previously been granted leave to

enter or remain as the dependant of the PBS main
applicant on which you are dependent?
Yes
Now go to Section D
No
Section D Details of your Representative

In this section you will be asked to provide information about your representative such as their
name, address and contact details. It also asks whether or not they are appropriately registered or
regulated to provide immigration advice.
D1; Do you have a representative acting on your behalf on this application?
Yes
go to D2
No
go to Section E
D2; What is the name of your representative? (ht)
D3; What is the name of your representatives organisation? (ht)
D4; Is your representative based in the UK?

Yes
go to D5
No
go to D6
D5; What is their UK Address?

House number/name
Address line 1
Address line 2
Address line 3
Town/City
Postcode
Now go to D7
D6; What is their overseas address?
House number/name
Address line 1
Address line 2
Address line 3
Town/City
County/District
Country
Postcode

D7; Please provide your representatives contact details:
Work telephone number
Mobile telephone number
Email address line 1
Fax number
D8; Is your representative regulated by the Office of the Immigration Services Commissioner
(OISC)? (ht)
Yes
go to D9
No
go to D10
D9; What is their OISC registration

number?
Now go to D11
D10; What is the reason that they are not OISC registered?
They are authorised by designated professional body or regulator
They are registered or authorised in an EEA State
They are supervised
They are exempt or employed or supervised by exempt person
They are specified by an order
I dont know
Now go to Section E
Section E - Your Contact Details in the UK

In this section you will be asked to provide information about how we can contact you, including
your correspondence address in the UK, contact telephone numbers, email address, etc
E1; Do you live at the same address as the PBS main applicant that you are dependant on?
(ht)
Yes
go to E3
No
go to E2
E2; Why do you not live at the same address as the PBS main applicant that you are
dependant on?
E3; What is your current address? (ht)

House number/name
Address line 1
Address line 2
Address line 3
Town/City
County/District
Country
Postcode
E4; What date did you move to this address? (ht)
D
E5; Is your correspondence address the same as your current address (as given above)?
(ht)
Yes
go to E7
No
go to E6
E6; What is your correspondence address?
House number/name
Address line 1
Address line 2
Address line 3
Town/City
County/District
Country
Postcode

E7; Please provide the following contact details:
Work telephone number
Home telephone number
Mobile telephone number
Fax number
E8; Please tick to indicate what your preferred contact telephone number is:
Work
Home
Mobile
Now go to Section F
Section F - Your Reference Numbers

In this section you will be asked to provide information about any Home Office reference numbers
that you might have. These can be found on documents and correspondence we have previously
sent to you. You will also be asked to provide any current and any previous National Insurance
number.
F1; Have you ever had a Home Office reference number assigned to you? (ht)
Yes
go to F2
No
go to F3
F2; What is/are your Home Office reference number(s)?

You may enter up to 3 reference number below:
Reference number 1
Reference number 2
Reference number 3
F3; Do you currently have a National Insurance number? (ht)
Yes
go to F4
No
go to F5
F4; What is your National Insurance number? (ht)
F5; Have you previously had a National Insurance number? (ht)

Yes
go to F6
No
go to Section G
F6; What was your previous National Insurance number? (ht)
Now go to Section G
Section G - About your Passport or Travel Document

In this section you will be asked to provide information about your current and previous passports
or travel documents. If you have lost or had any passports or travel documents stolen then you
should have reported this to the Police and you will be asked to provide information about this.
G1; Please provide the following details: (ht)
Current Passport or Travel Document
What
is your
current
passport
or travel
document
number?
What
What is
is the
the issue
nationdate?
ality
on the
passport?
What is
What is
the expiry the place
date?
of issue?
Is the
passport
or travel
document
enclosed?
If the passport or
travel document is
not enclosed, please
indicate why:
Yes -
Lost - go to G2
go to G4
Stolen - go to
G3
No go to next
column
Expired and
returned
to national
authorities - go
to G4
Already with
The Home
Office - go to
G4
G2; Please explain how you lost your passport: (ht)

What was the Police
report number?
What was the crime

reference number?
Which police station

was this reported at?
What date was this

reported to the Police
on?

G4: Have you had a previous Passport or Travel Document? (ht)
Yes
go to G5
No
go to Section H

Previous Passport or Travel Document
What is the
passport
or travel
document
number?
What is the What is

nationality the issue
on the
date?
passport?
What is
the expiry
date?
What is the Is the

place of
passport
issue?
or travel
document
enclosed?
If the passport or
travel document is
not enclosed, please
indicate why:
Yes -
Lost - go to G6
go to
Section H
Stolen - go to
G7
No -
Expired and
returned
to national
authorities go
to Section H
go to next
column
Already with
The Home
Office
G6; Please explain how you lost your passport: (ht)

What was the Police
report number?
What was the crime

reference number?

What date was this

on?
Section H - About your Biometric Residence Permit

In this section you will asked to provide information about any Biometric Residence Permit(s) that
have previously been issued to you
H1. Do you have a BRP?
Yes
go to H2
No
go to H7
H2. Please provide the following details: (ht)

Biometric Residence Permit
What is your What is your What is
BRP number? nationality on the issue
the BRP?
date?
What is
Is your BRP
If the BRP is not
the expiry enclosed
enclosed please
date?
with this
indicate why:
application?
Yes - go to
Lost - go to H3
H7
Stolen - to go
H4
No - go
to next
column
Expired and
returned
to national
authorities - go
to H7
Already with
The Home
Office - go to
H7
H3. Please explain how you lost your BRP: (ht)
H4. Please provide the following details: (ht)

What was the Police
report number?
What was the crime

reference number?

What date was this

on?
H5. Have you reported this to the The Home Office card management service? (ht)
Yes
go to H6
No
go to H7
H6. What date did you report this? (ht)

D

H7. Which age group do you belong to (at the date of submitting your application)?
15 years & under
go to H8
16 years & over
go to
Section I
H8. What is the title of the person accompanying you to have your biometric details taken?
Mr
Mrs
Miss
Ms
Other (please state)
H9. First name(s) or given name(s)
H10. Last name(s) or family name(s)
H11. Their date of birth
H12. Their place of birth
H13. Relationship to you
H14. Is this person your parent or legal guardian

Yes
go to Section I No
go to H15
H15. Explain why your parent or legal guardian will not be accompanying you
Now go to Section I
Section I - About your Previous Addresses

In this section you will be asked to provide information about any previous addresses in the UK,
including Northern Ireland, where you have lived in the last five years.
I1; Have you previously lived in Northern Ireland? (ht)
Yes
go to I2
No
go to I5
I2; What was your address? (ht)

House number/name
Address line 1
Address line 2
Address line 3
Town/City
County/District
Country
Postcode
I3; What date did you move to this address? (ht)
D
I4; What date did you move from this address? (ht)
D
If you have lived at more than one address in Northern Ireland, please continue on a separate
sheet.
I5; Have you lived at any other addresses in the UK within the last 5 years? (ht)
Yes
go to I6
No
go to Section J
I6; What was your address?

House number/name
Address line 1
Address line 2
Address line 3
Town/City
County/District
Postcode
I7; What date did you move to this address?
D

I8; What date did you move from this address?
D
If you have lived at more than one address in the last five years, please continue on a separate
sheet.
Now go to Section J
Section J - About your Personal History

In this section you will be asked to provide information about any criminal convictions you have, any
civil judgements or immigration civil penalties against you and details of any involvement you may
have had in war crimes, genocide, crimes against humanity or terrorism.
J1; Have you ever been convicted of a criminal offence either in the UK or in another
country? (ht)
Yes
go to J2
No
go to J7
J2; What was the offence?
J3; What was the sentence given?
J4; If you were sentenced to a period of imprisonment, what was the length of the prison
sentence in months?
J5; What date were you sentenced on?

D
J6; Which country were you convicted in?
J7; Have you ever had any civil judgements issued against you or received a civil penalty
under the UK Immigration Acts? (ht)
Yes
go to J8
No
go to J11
J8; Please provide details of the judgement or civil penalty:

J9; Date of the judgement or civil penalty
D
J10; Which country was the judgement issued in?
J11; Have you ever been charged or indicted in any country with a criminal offence for which
you have not yet been tried in court?
Yes
go to J12
No
go to J13
J12; Please provide details of the offence:
J13; In either peace or war time, have you ever been involved in, or suspected of
involvement in, war crimes, crimes against humanity or genocide? (ht)
Yes
go to J14
No
go to J15
J14; Please provide details:
J15; Have you ever been involved in, supported or encouraged terrorist activities in any
country? (ht)
Yes
go to J16
No
go to J17

J17; Have you ever been a member of, or given support to an organisation which has been
concerned with or involved in terrorism? (ht)
Yes
go to J18
No
go to J19
J19; Have you, by any means or medium, expressed views that justify or glorify terrorist
violence or that may encourage others to commit terrorists acts or activities or other serious
criminal activities? (ht)
Yes
go to J20
No
to to Section K
Now go to Section K
Section K - About your Immigration History

In this section you will be asked to provide information about your current and previous immigration
status in the UK, including previous applications that you have made.
K1; What is your current immigration status?
I have leave to enter / remain for a limited period - Go to K4
I am an EU national / family member of an EU national - Go to K4
I am exempt from immigration control - Go to K4
I have leave to enter / remain for a limited period, but leave has now expired - Go to K2
None of the above - go to K4
K2; Did this leave expire more than 28 days before this application was made?:
Yes - Go to K3
No - Go to K4
K3; I am submitting evidence of exceptional circumstances which prevented me from

submitting my application within 28 days of overstaying.
Tick to confirm
K4; Were you required to register with the Police as a condition of your previous leave? (ht)
Yes
No
K5; Did you have a visa or entry clearance when you came to the UK? (ht)
Yes
go to K6
No
go to K10
K6; In which country did you obtain your visa or entry clearance? (ht)
K7; What is the reference number of the visa or entry clearance? (ht)
K8; What date was your visa or entry clearance valid from? (ht)
D
K9; What date was your visa or entry clearance valid to? (ht)
D

K10; How did you enter the UK? (ht)
By air
By sea
By the Channel Tunnel
Travelling overland via the Republic of Ireland
K11; At which port did you enter the UK? (ht)
K12; What was your ticket booking or reference number? (ht)
K13; What was the name of your transport operator? (ht)
K14; Have you ever stayed in the United Kingdom beyond the expiry date of your period of
leave? (ht)
Yes
go to K15
No
go to K16
K15; Please provide details: (ht)
K16; Have you ever knowingly used deception when seeking leave to enter or remain,
entered the United Kingdom illegally or worked in the United Kingdom without immigration
permission to do so (contrary to your conditions of stay)? (ht)
Yes
go to K17
No
go to K18
K18; Have you ever been refused entry clearance, leave to enter or leave to remain in the
UK? (ht)
Yes
go to K19
No
go to K20

K20; Have you ever been removed, required to leave or deported from the UK? (ht)
Yes
go to K21
No
go K22
K22; Do you currently have any other applications with the Home Office on which you are
awaiting a decision? (ht)
Yes
go to K23
No
go to K24
K24; Do you currently have an immigration appeal before the Tribunal which has not yet
been finally determined? (ht)
Yes
go to K25
No
go to Section L
Now go to Section L
Section L - Public Funds

In this section you will be asked to provide information about whether or not you have claimed
public funds (benefits and housing) in the UK and details about any claims you have made.
L1; Have you ever claimed any public funds? (ht)
Yes
go to L2
No
go to Section M
L2; Have you claimed Attendance Allowance?

Yes
No
L3; Have you claimed Carers Allowance?

Yes
No
L4; Have you claimed Child Benefit?

Yes
No
L5; Have you claimed Tax Credit?

Yes
No
L6; Have you claimed Council Tax Benefit?

Yes
No
L7; Have you claimed Disability Living Allowance?

Yes
No
L8; Have you claimed Housing or Homelessness Assistance?

Yes
go to L9
No
go to L10
L9; What is the name of the local housing authority or housing association that provided
this?
L10; Have you claimed Housing Benefit?

Yes
No

L11; Have you claimed Income-based Jobseekers Allowance?
Yes
No
L12; Have you claimed Income Support?

Yes
No
L13; Have you claimed Severe Disablement Allowance?

Yes
No
L14; Have you claimed Social Fund Payments?

Yes
No
L15; Have you claimed State Pension Credit?

Yes
No
L16; Have you claimed Working Tax Credit?

Yes
No
L17; Have you claimed Income-related Employment and Support Allowance?

Yes
No
L18; Is your housing provided by a local authority or housing authority as part of an

agreement between your employer and a housing authority? (ht)
Yes
No
L19; Have you claimed Council Tax Reduction?
Yes
No
L20; Have you claimed Personal Independence Payment?

Yes
No
L21; Have you claimed Universal Credit?

Yes
No
Now go to Section M
Section M - About your Maintenance

In this section you will be asked to provide information about maintenance which is the money you
will need for your living costs in the UK.
It is essential that you ensure that the information you provide in this section is accurate. We use
this information to advise you of the amount of money you will need for maintenance.
M1; Are you applying for leave at the same time as the PBS main applicant that you are
dependant upon?
Yes
go to M2
No
go to M4
M2; Under which category of the Points Based System is the main applicant applying?
Tier 1 (General) - go to M6
Tier 1 (Entrepreneurs) - go to M7
Tier 1 (Graduate Entrepreneur) - go to M10
Tier 1 (Exceptional Talent) - go to Section N
Tier 1 (Investors) - go to Section N
Tier 1 (Post Study Work) - go to M7
Tier 5 (Temporary Worker) - All categories - go to Section M11
M3; Is the PBS main applicant making:
An initial switching application - go to M11
An application for an extension of their existing leave - go to section N
An application following a change of employment - go to Section N
M4; Has the PBS main applicant received notification that their application has been
successful? (ht)
Yes
No
M5; Under which category of the Points Based System has the main applicant applied?
Tier 1 (General) - go to M6
Tier 1 (Entrepreneurs) - go to M7
Tier 1 (Graduate Entrepreneur) - go to M10
Tier 1 (Exceptional Talent) - go to Section N
Tier 1 (Investors) - go to Section N
Tier 1 (Post Study Work) - go to M7
Tier 5 (Temporary Worker) - All categories - go to M11

M6; Has the PBS main applicants application been assessed in accordance with paragraphs
39 to 42 of the HSMP Forum Ltd. Judicial Review Policy Document?
Yes
No
M7; How long has the PBS main applicant been in the UK for?
Less than 12 months - go to M8
More than 12 months - go to M9
M8; Please tick the box below:
I can confirm that I am providing evidence of having 1890 in available funds.
Go to M12
M9; Please tick the box below:
I can confirm that I am providing evidence of having 630 in available funds.
Go to M12
M10; How are you able to demonstrate that you have sufficient funds available to you?
I am providing an endorsement letter confirming that UK Trade
and Investment (UKTI) has awarded funding to cover the required
maintenance - go to section N
Where PBS migrant has been in the UK less than 12 months
I am providing evidence of having 1260 in available funds - go to M12
Where PBS migrant has been in the UK more than 12 months
M11; How are you able to demonstrate that you have sufficient funds available to you?
M12; You must provide evidence that you have access to available funds in order to support
yourself. Please tick the relevant box to confirm what evidence you are supplying:
Personal bank or building society statements covering a consecutive 90 day period
A building society pass book covering a consecutive 90 day period
A letter from a bank or building society confirming the funds and that they have
been held for a consecutive 90 day period

A letter from a financial institution regulated by either the Financial Conduct
Authority, the Prudential Regulatory Authority or, in the case of overseas accounts,
the home regulator (official regulatory body for the country in which the institution
operates and the funds are located) for the purpose of personal savings accounts,
confirming the funds and that they cover a consecutive 90 day period.
Now go to Section N
Section N - About your Personal Circumstances/attributes

In this section you will be asked about your relationship with the PBS main applicant that you are
dependent upon.
N1; What is your relationship to the PBS main applicant that you are dependent on?
Spouse - go to N2
Civil Partner - go to N2
Unmarried Partner - go to N2
Same-Sex Partner - go to N2
Dependent Child under 18 - go to N7
Dependent Child 18 or over - go to N7
N2; Is your relationship with your Spouse/Civil Partner subsisting?
Yes
No
N3; Do you intend to live with your Spouse/Civil Partner throughout your time in the UK?
Yes
No
N4; Do you intend to remain in the UK beyond the period of leave that your Spouse/Civil
Partner has or may be given?
Yes
No
N5; Do you intend to live with them throughout your stay in the UK?
Yes
No
N6; Was your last grant of leave to enter or remain as the spouse/civil partner of the PBS
main applicant?
Yes
No
Now go to the next section

N7; Have you previously been granted leave as the dependent child of the PBS main
applicant?
Yes
No
N8; Are you married or in a civil partnership?
Yes
No

N9; Have you formed an independent family unit from your parent or are you living an
independent life?
Yes
No
N10; Do you intend to remain in the UK beyond any period of leave your parent (the PBS
main applicant) has or may be given?
Yes
No
N11; Are both of your parents lawfully present in the UK?
Yes
No
N12; Are both of your parents applying for leave at the same time as you?
Yes
go to the next section
No
go to N13
N13; Is the PBS main applicant that you are dependent upon your sole surviving parent?
Yes
go to the next section
No
go to N14
N14; Has the PBS main applicant you are dependent upon had, and still has, sole
responsibility for your upbringing?
Yes
go to next section
No
go to N15
N15; Is your other parent in the UK?
Yes
No
Now go to the next section
Section O - Your Declaration

You must complete part O. If it is not complete, then your application will be invalid and will be
returned to you.
You must sign below to show that you have read and understood the following declaration. It must
be authorised by you and not by a representative or other person acting on your behalf. If you are
under 18, your parent or legal guardian may sign.
The information given in my application is complete and is true to the best of my knowledge and
belief.
The photographs I have submitted with my application are a true likeness of me.
The documents I have submitted in support of my application are complete and correct to the best
of my knowledge and belief.
I agree to co-operate with Home Office officials, or any other person charged by the
Secretary of State for the Home Office with conducting pre-issue and post-issue checks in relation
to this application.
If there is a material change in my circumstances or any new information relevant to this
application becomes available before it is decided, I will inform the Home Office.
I am aware that the rules and requirements for applications may change in the future and that I
should not assume the current rules and requirements will continue to apply.
I agree to the Home Office using the data provided in this application in accordance with its
Information Charter.
I understand that my details may in certain circumstances be passed to fraud prevention agencies
to prevent and detect fraud and money laundering. I also understand that such agencies may
provide the Home Office with information about me. Further details explaining when information
may be passed to or from fraud prevention agencies and how that information may be used can
be obtained from the Home Office website.
I understand that if I am informing the Home Office that I have changed my gender, these details
may in certain circumstances be shared with other Home Office colleagues. I consent to this,
where necessary and understand that this information will only be shared in limited circumstances
relating to identity and security in line with Section 22 of the Gender Recognition Act. I am aware
they will otherwise be treated in confidence and that my rights under the Equality Act 2010, Data
Protection Act 1998 and Article 8 of the European Convention on Human Rights will be unaffected.
Name
Signature
Date
D
Section P - Representatives Declaration

If you are a representative acting in relation to this application you must complete the declaration
below to show you have read and understood the representatives declaration and to confirm that
you are authorised to act on behalf of the applicant(s).
I have been appointed by the applicant(s) to act on their behalf in relation to this application which
has been submitted online to the Home Office.
I confirm that I am aware of the contents of this application, including its supporting documents, and
that the application is, to the best of my knowledge and belief, true and correct.
I confirm that I will promptly give the applicant all correspondence I receive from the Home Office
about this application.
I am permitted to give immigration advice and immigration services by virtue of section 84 of the
Immigration and Asylum Act 1999.
I am aware that it is an offence to do an act which facilitates a person who is not a citizen of the
European Union to commit a breach of immigration law, knowing or having reasonable cause to
believe that the act has this effect.
Name
Signature
Date
D
Name of your organisation:
Your position within the organisation:
Section Q - Supporting Documents

Fill in this part of the form to help us make sure that we have received your documents and
to keep a record of them while they are with us.
From list A, tell us how many of each of the listed documents you have sent with this
application. This is a standard list, you should only send in the documents from this list that
are required for your application. At B, list any other documents you have sent and state
how many in each case. Continue on a separate sheet if necessary.
A. Type of document
How
many?
B. Listed items
Passports
Biometric Residence Permit and/

or travel documents
Police registration certificates

Evidence of care arrangements if
you are under 18 years old
Passport Photographs
Marriage/civil partnership
certificate (where not previously
granted as dependant)
Full Birth certificates (applicants
under 18 not previously granted
as dependants)
Utility bills (water, Gas, Electric)
Bank statements
Council tax bill
How
many?

T1 or 5 Dependant Form November 2015

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T1 or 5 Dependant Form November 2015

Încărcat de

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Formate disponibile

Tier 1 or 5 PBS

Application for a Grant of Leave and

TIER 1 OR 5 DEPENDANT APPLICATION FORM

Tier 1 or 5 Dependant Application Form (Version 11/2015) - page 2 of 35

TIER 1 OR 5 DEPENDANT APPLICATION FORM

Section A - Payment Details

Section A - Application Details

Tier 1 Exceptional Talent

Tier 1 Exceptional Talent Extension

Tier 1 Graduate Entrepreneur standard

Tier 1 or 5 Dependant Application Form (Version 11/2015) - page 3 of 35

TIER 1 OR 5 DEPENDANT APPLICATION FORM

A2.1 Correspondence address

Contact name in the UK if different to that of the dependant.

Your full name

A2.4 Your date of birth

A2.5 Main Applicants full name

A2.6 Main Applicants date of birth

A2.8 Paying by cheque - please give cheque details below

A2.13 Cardholders signature

3 digit number Security No - CVV

Tier 1 or 5 Dependant Application Form (Version 11/2015) - page 4 of 35

TIER 1 OR 5 DEPENDANT APPLICATION FORM

If you are producing a double-sided copy of this

Tier 1 or 5 Dependant Application Form (Version 11/2015) - page 5 of 35

TIER 1 OR 5 DEPENDANT APPLICATION FORM

Section B Your personal details

First name(s) or given name(s):

Last name(s) or family name(s):

B2; What is your gender?

B3; What is your date of birth?

B4; What is your relationship status? (ht)

Dissolved Civil Partnership

Surviving Civil Partner

Tier 1 or 5 Dependant Application Form (Version 11/2015) - page 6 of 35

TIER 1 OR 5 DEPENDANT APPLICATION FORM

B6; What is your country of birth?

B7; What is your current nationality? (ht)

Please tick to confirm that you are submitting the required

Please tick to confirm that you are submitting the required

Tier 1 or 5 Dependant Application Form (Version 11/2015) - page 7 of 35

TIER 1 OR 5 DEPENDANT APPLICATION FORM

First name(s) or given name(s):

Last name(s) or family name(s):

C5; Have you previously been granted leave to

Tier 1 or 5 Dependant Application Form (Version 11/2015) - page 8 of 35

TIER 1 OR 5 DEPENDANT APPLICATION FORM

Section D Details of your Representative

D2; What is the name of your representative? (ht)

D3; What is the name of your representatives organisation? (ht)

D4; Is your representative based in the UK?

D5; What is their UK Address?

Tier 1 or 5 Dependant Application Form (Version 11/2015) - page 9 of 35

TIER 1 OR 5 DEPENDANT APPLICATION FORM

D9; What is their OISC registration

Tier 1 or 5 Dependant Application Form (Version 11/2015) - page 10 of 35

TIER 1 OR 5 DEPENDANT APPLICATION FORM

Section E - Your Contact Details in the UK

E3; What is your current address? (ht)

Tier 1 or 5 Dependant Application Form (Version 11/2015) - page 11 of 35

TIER 1 OR 5 DEPENDANT APPLICATION FORM

Tier 1 or 5 Dependant Application Form (Version 11/2015) - page 12 of 35

TIER 1 OR 5 DEPENDANT APPLICATION FORM

Section F - Your Reference Numbers