PROTECTING VICTIMS OF DOMESTIC VIOLENCE (DDV)
Appendix 1: Request for Fee Waiver You should only complete this form if:
You are applying for leave to remain in the UK on the basis of family or private life; or
You are applying for leave to remain in the UK on the basis of an ECHR right; or
You are applying for further leave to remain in the UK on the basis that you were granted Discretionary Leave following refusal of asylum or humanitarian protection and that to refuse you an extension would breach your rights under the ECHR; or
You are a victim of trafficking or slavery who has had a positive conclusive grounds decision from a competent authority of the national referral mechanism and you are seeking to extend beyond 30 months Discretionary Leave granted to you for reasons related to your trafficking or slavery.
Please ensure that you also complete and submit the relevant application form. You should only complete this form if you are seeking a fee waiver because you think you meet the published fee waiver policy. This will be because you are destitute, or because you would become destitute if you paid the fee (in respect of your own application or one or more of your dependants included in the application), or because there are exceptional circumstances relating to your financial circumstances which mean that you are unable to pay the fee for your application (or for that of one or more of your dependants). Definition of destitution You will be destitute if: a) b)
You do not have adequate accommodation or any means of obtaining it (whether or not your other essential living needs are met); or You have adequate accommodation or the means of obtaining it, but cannot meet your other essential living needs.
You must complete every section of this form.
You should not pay the Immigration Health Surcharge (IHS) if you are applying for a fee waiver. Applicants who are granted a fee waiver are not required to pay the IHS. 1 August 2017
However, applicants who are refused a fee waiver and who are required to pay a fee in order to validate their application, will be required to pay the IHS at that stage. If you wish to use a representative to assist you in completing this form, you should ensure that they are qualified to provide advice (see Find an immigration Adviser). The decision on whether you qualify for a fee waiver will be made on the basis of the information you provide in this form and the evidence submitted with it. It is your responsibility to provide sufficient information and evidence to demonstrate that you qualify for a fee waiver. You will need to provide documentary evidence with this fee waiver application to demonstrate your financial circumstances. The nature of this evidence will vary according to your individual circumstances, but some examples of relevant documents you may wish to include are listed below. Please note:
Documents from an official source must be on letter headed paper.
Letters from charities must show the registered charity number. Copies of documents such as bank and building society documents must be certified by the bank/financial institution.
If you live with a partner or with a family member or friend who supports you financially, you must provide evidence of their financial circumstances in addition to your own.
You must also provide evidence of the financial circumstances of all your dependants.
Please tick the boxes below to show which documents you are sending with your application: Bank statements covering the period of six months prior to the application Savings account statements covering the period of six months prior to the application Tenancy agreement or mortgage documents Utility and other relevant bills no more than three months old Letter confirming employment (the person writing should state their position in the company and contact details) Pay slips covering the period of six months prior to the application 2 August 2017
P60 End of Year Certificate: showing the amount of tax and National Insurance (NI) contributions paid in the tax year P45 Details of an employee leaving work: showing the amount of tax and NI contributions paid by the employee up to the date of leaving the employment Letters from a registered charity or Local Authority confirming you are in receipt of support from them Letters from any friends or family who are providing you with support explaining what support they are providing and if they are stopping that support why they are doing so Letters confirming you or your spouse/partner are in receipt of public funds Other documents – see box below. If you are including other documents (including any that you are asked to provide when answering the questions in the form), please give details in the box below:
This form is not an application for leave to remain. It is to enable a decision to be made on whether you qualify for a fee waiver for your separate application for leave to remain. If you qualify for a fee waiver, your application for leave to remain will then be considered. The granting of a fee waiver does not guarantee that your application for leave to remain will be successful. If you do not qualify for a fee waiver, your application may be invalid due to non-payment of the fee. If you applied in time, you will be advised in writing how you can make a valid application.
3 August 2017
Section 1 – basis of fee waiver application 1.1. Who is applying for a fee waiver? List below all the individuals who are included in your application for leave to remain in the UK (you will need to use the relevant form to make the application for leave to remain). Indicate which of them are also applying for a fee waiver. Main applicant name [ Dependant 1 name [ Dependant 2 name [ Dependant 3 name [ Dependant 4 name [ Dependant 5 name [ Dependant 6 name [
] fee waiver? [Y] [N] ] fee waiver? [Y] [N] ] fee waiver? [Y] [N] ] fee waiver? [Y] [N] ] fee waiver? [Y] [N] ] fee waiver? [Y] [N] ] fee waiver? [Y] [N]
1.1. Please tick the basis on which you and/or are applying for a fee waiver: I am destitute (see definition above). I am not destitute but I would become destitute if I paid the application fee Or (indicate which) I am not destitute but I would become destitute if I paid the fee for my own application and for the application for all of the dependants included in the application. I am not destitute and would not become destitute if I paid the application fee, but I have exceptional circumstances relating to my financial circumstances which mean I am unable to pay the fee for my own application and all of the dependants included in the application. Please provide an explanation below for why you have ticked the particular box above and continue on a separate sheet if necessary:
4 August 2017
Section 2 – Personal details
Title: Mr Gender:
Mrs Male
Miss
Ms
If other what is your title? Other
Female
Date of Birth (day/month/year): Your full name as in your passport or travel document: Surname or family name: Given name Any other name(s) by which you are or have been known: Nationality: Place of birth – town or city and country Passport, national identity card or travel document number: Home Office reference if you have one: National insurance number if you have one: BRP reference number (if you have one): 5 August 2017
What is your marital status:
Married
Single
Separated
Divorced
Civil partnership
Same Sex Partner
Widowed
Unmarried partner
Dissolved partnership
Surviving Civil partner
Personal details of your spouse/partner Is your spouse/partner currently in the UK?
Yes
No
Name of spouse/partner: Date of birth of your spouse/partner (day/month/year): Nationality of your spouse/partner: Personal details of your parents If you are a child aged under 18 please provide details of your parent(s). Name of parent 1: Date of birth of your parent (day/month/year): Nationality of your parent: Is this parent currently in the UK?
Yes
No
Name of parent 2: Date of birth of your parent (day/month/year): Nationality of your parent: Is this parent currently in the UK?
Yes
No
6 August 2017
Disability Do you consider yourself to be disabled?
Yes
No
Are any family members on whom you are dependent disabled? Are any of your dependent family members disabled?
Yes
Yes
No No
If yes, please provide full details of your or your dependent family member’s disability (and enclose relevant documentary evidence of this) and of any impact this has on your financial circumstances:
7 August 2017
Section 3 – Dependent family members Please complete this section for any children under the age of 18, or any other dependent family members, who are living with you in the UK. Please specify whether they are dependants on your application. Details of your dependent family member Name: Place of birth: Date of birth (day/month/year): Gender: Male
Female
Nationality: Home Office reference number (if known):
Details of your dependent family member Name: Place of birth: Date of birth (day/month/year): Gender: Male
Female
Nationality: Home Office reference number (if known):
If you have more than two dependent family members, please provide details on a separate sheet of paper.
8 August 2017
Section 4 – Your current accommodation 4.1 What address can we contact you at? House/Flat Number: Street Name: Town or City: County: Post Code: 4.2 Is this where you are currently living? Yes
No
4.3 If yes, when did you move into your current address?
If no, where are you currently living? Please provide the full address. If you are homeless please state this clearly. House/Flat Number: Street Name: Town or City: County: Post Code:
4.4 Please provide details of any previous UK addresses in the last five years: House/Flat Number: Street Name: Town or City: County: Post Code: Continue on a separate page if necessary. 4.5 Have you been asked to leave the accommodation in which you are currently living? Yes
No
4.6 If Yes, please provide details of why this is:
9 August 2017
Please provide documentary evidence such as a formal eviction notice. 4.7 Do you own or rent your home? Please specify: Own home Rent home Neither own nor rent home
4.8 If you do not own or rent your home who presently provides you with accommodation? Friend Relative Refuge Local Authority Registered charity Other Please provide a letter from your accommodation provider to confirm your living arrangements. If you live with a friend or relative, please provide a letter of support along with evidence of residence such as a utility bill in their name. If you have stated “other” please give details in the box below:
4.9 How many bedrooms are in the property?
4.10 How many rooms (not including kitchens/bathrooms/toilets) are in the property?
4.11 Who do you live with and what is their relationship to you? (List each person living with you, including all children)
10 August 2017
4.12 Do you pay for your accommodation costs or contribute towards them? Yes
No
If yes, please specify how much you pay, and how regularly you pay this (weekly/monthly):
4.13 Does anyone (including a Local Authority) support you financially or by providing your essential living needs such as food? If so, provide details below of who supports you, what form the support takes (cash, vouchers, food, etc.), how much support you are given and how often:
4.14 Are they able to continue supporting you? Yes
No
If you ticked the “no” box, please explain why.
Please provide documentary evidence of their financial circumstances such as annotated bank statements and payslips. 11 August 2017
4.15 Are you homeless tonight? Yes
No
4.16 Will you be homeless shortly? Yes
No
If yes, please explain why:
4.17 If yes, on what date will you become street homeless (day/month/year):
4.18 If you are homeless or at risk of homelessness, which organisations/charities/agencies have you approached for assistance? Please provide a recent letter from these sources. Section 5 – Your financial details Please note we require evidence of your finances, including bank statements, building society savings books or other formal documentation in support of your application for a fee waiver. This evidence should cover the six month period prior to your application being submitted. If you are being supported by a friend or relative, we require written evidence in the form of a letter confirming this, with formal documentation showing that person’s financial resources. If you are being supported by a registered charity or a Local Authority, we also require formal documentation to evidence this. Please provide full details of exactly what the support consists of, why you are eligible for such support and when the support began. 5.1 Have you received any support from friends since arriving in the UK? Yes
No
If yes, please provide details:
12 August 2017
5.2 Have you received any support from relatives since arriving in the UK? Yes
No
If yes, please provide details:
5.3 Are you able to borrow money for the application fee from family and/or friends? Yes
No
5.4 If you are already receiving financial support from family and/or friends, please provide documentary evidence to confirm whether you are able to borrow the application fee from them. 5.5 Have you received any support from a former partner? (This includes any child maintenance payments) Yes
No
If yes, please provide details:
5.6 Have you received any compensation or damages payments? Yes
No 13
August 2017
If yes, please provide details:
5.7 Do you have any of the following (you must tick any or all you have): Cash savings in the UK or overseas Bank or building society accounts in the UK or overseas (including accounts held by partner/dependent children) Number of accounts held by you: Number of accounts held by partner: Number of accounts held by dependent children: Investments Property in the UK Property outside the UK Land in the UK Land outside the UK Jewellery (except for wedding jewellery) TV, DVD player, electrical goods Car or other vehicle 5.8 Can you sell any of these non-cash assets? Yes
No
5.9 If you ticked yes, please explain why you have not sold the asset. If you ticked no, please explain why you cannot sell the asset.
14 August 2017
5.10 What is the value of each of the assets you ticked in question 5.7?
Please specify the relevant currency:
5.11 If you have money or investments held in a bank account in the UK or overseas, please provide the name of the bank/building society/other financial institution in which the funds are held and the name of the country in which the account is held:
You must list each account held (including accounts held in the names of any dependent children) and provide statements covering the period of six months prior to the application being submitted for each account held. 5.12 If the bank account(s) held is not in the UK, are you able to access it from within the UK? Yes
No
If no, please explain why not:
5.13 Please list any other material or monetary assets you own, and their approximate value:
15 August 2017
5.14 Are you currently working in the UK, or do you have a confirmed offer of employment? Yes
No
5.15 If you ticked yes above because you are working in the UK, please provide details of the nature of the employment or self-employment:
5.16 If you ticked yes above because you are working in the UK, please provide details of your employment income and how frequently it is paid (weekly/monthly/annually):
Please provide documentary evidence of all employment income in the period of six months prior to the application being submitted, such as payslips, bank statements and your most recent P60/P45.
5.17 If you ticked yes above because you have a confirmed job offer, please provide details here, including the amount of employment income you expect to earn, and how frequently this will be paid, and when the employment will begin:
16 August 2017
Section 6 – Public funds 6.1 Do you receive any of the following public funds? You must declare any or all of the following you receive:
Attendance allowance Carer’s allowance Child benefit Child tax credit Contribution-based jobseeker’s allowance Contribution-based employment and support allowance Council tax support Disability living allowance Housing benefit Housing and homelessness assistance Incapacity benefit Income-based jobseeker’s allowance Income-related employment and support allowance Income support Personal independence payment Pension credit Severe disablement allowance Social fund payment State pension credit Universal credit Working tax credit
Yes
No
If yes, please state for each public fund you are receiving: Type of benefit or allowance
Date you started receiving it (day/month/year)
How often do you receive it?
How much do you receive?
Please continue on a separate sheet if necessary.
17 August 2017
Section 7 – Spouse/partner/parent financial details Please note: you need only provide details of your parents if you are living with one or both of them and they are currently supporting you, or if you are a child aged under 18. 7.1 Is your spouse/partner or either of your parents currently employed or working in the UK, or do they have a confirmed offer of employment? Yes
No
Please provide documentary evidence of your spouse/partner/parents’ employment income in the period of six months prior to the application being submitted, such as payslips, bank statements and their most recent P60/P45 7.2 If you ticked yes above because your spouse/partner or either of your parents is working in the UK, please provide details of the nature of the employment or selfemployment:
7.3 If you ticked yes above because your spouse/partner or either of your parents is working in the UK, please provide details of their employment income and how frequently it is paid (weekly/monthly/annually):
7.4 If you ticked yes above because your spouse/partner or either of your parents has a confirmed job offer, please provide details here, including the amount of employment income they expect to earn, and how frequently this will be paid, and when the employment will begin.
18 August 2017
7.5 Does your spouse/partner or either of your parents have any of the following assets (you must tick any or all of the assets they have): Cash savings in the UK or overseas Bank or building society accounts in the UK or overseas Number of accounts held by spouse/partner/parents: Investments Property in the UK Property outside of the UK Land in the UK Land outside the UK Jewellery (except for wedding jewellery) TV, DVD player, electrical goods Car or other vehicle Can your spouse/partner or either of your parents sell any of these non-cash assets? Yes
No
7.6 If you ticked yes, please explain why they have not sold the asset. If you ticked no, please explain why they cannot sell the asset.
7.7 What is the value of each of the assets belonging to your spouse/partner or either of your parents that you ticked in question 7.5? 19 August 2017
Please specify the relevant currency:
7.8 If your spouse/partner or either of your parents has money or investments held in a bank account within the UK or overseas, please provide name of bank or building society/other in which the asset is held and the name of the country where these assets are:
7.9 If the bank accounts held are not in the UK, is your spouse/partner or either of your parents able to access them from within the UK? Yes
No
7.10 Does your spouse/partner or either of your parents receive any public funds? Yes No Question 6.1 has a list of what constitutes public funds. Please refer to this list if you are unsure. If Yes, please state for each public fund your spouse/partner is receiving: Type of benefit or allowance
Date your spouse/partner started receiving it (day/month/year)
How often does he or she receive it?
How much does he or she receive?
Please continue on a separate sheet if necessary.
Section 8 – Additional Information 20 August 2017
Please provide any additional information that you would like us to take into account in determining whether you qualify for a fee waiver. Please continue on a separate sheet if necessary.
21 August 2017
Section 9 – Household income and outgoings Please complete the following table with details of your household monthly income and outgoings. Your household monthly income should be based on the average monthly income your household received over the period of six months prior to the application. Your household includes you, your partner, your dependants and any other persons with whom you live and on whom you depend for financial support. Your monthly outgoings should be an average of your monthly outgoings based on the period of six months prior to the application. The information provided below should be supported by documentary evidence submitted with your application. A breakdown of your monthly income is as follows:
Wages (net wages after deductions):
A breakdown of your monthly outgoings is as follows:
£
Overtime (net after deductions):
£
State Benefits:
£
Tax (if self-employed)
£
National Insurance (if self-employed)
£
Rent/Mortgage
£
Car/Travel Expenses
£
Pension (Private/State):
£
Gas
£
Drawings from business:
£
Electricity
£
Profit from business:
£
Water
£
Income from trust:
£
Food
£
Clothing
£
Dividends from shares:
£ Mobile Phone
£
Interest from savings:
£ Telephone/Broadband
£
Assistance from family/friends:
£ Sky/Cable TV
£
Insurance
£
Assistance from Local Authority: Other (please specify):
£ £
Gym Membership £ Other (specify) lots of potential outgoings not listed here Total: £
Total: £
Please note: All figures provided on this form must be supported with evidence/documentation. Signed
Date: 22
August 2017
Declaration You must read the declaration below and sign it. This must 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 is mandatory for the declaration to be signed. Where one or more dependants of the main applicant are applying for a fee waiver, you must photocopy this declaration and a separate copy must be signed by each person applying for a fee waiver. Please note that this application will be rejected as invalid if it is not signed as specified above. I hereby apply for a fee waiver for myself. The information given by or about me in this form is complete and is true to the best of my knowledge. I confirm that if, before this application for a fee waiver is decided, there is a material change in my or my dependants’ circumstances or new information relevant to this application for a fee waiver becomes available, I will inform the Home Office. I understand that all information provided by me to the Home Office will be treated in confidence; that it may be disclosed to other government departments, agencies, local authorities, the police, foreign governments and other bodies for immigration purposes or to enable them to perform their functions; and that, if such bodies provide the Home Office with any information about me, which may be relevant for immigration purposes, it may be used in reaching a decision on my application. I understand that my details may 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 GOV.UK. I understand that documents provided in support of this application for a fee waiver will be checked for authenticity; and that false documents will be retained and may result in my application being refused and in my prosecution. I understand that the Home Office may also use the information provided by me for training purposes.
Signature: Print Name: 23 August 2017
Date:
Any friend, relative or other party whom the applicant has stated will provide financial support and/or is a joint customer with the applicant with a bank or utility company must ensure that they have also completed the consent for verification checks declaration which is included in the relevant leave to remain application form.
24 August 2017
Checklist: Have you completed all the questions on this form? Have you enclosed all documentary evidence required by this form? Have you enclosed a fully completed application form for leave to remain? (If not, or if you have enclosed the wrong form, your application may be rejected).
25 August 2017
You are applying for leave to remain in the UK on the basis of family or private life; or
You are applying for leave to remain in the UK on the basis of an ECHR right; or
You are applying for further leave to remain in the UK on the basis that you were granted Discretionary Leave following refusal of asylum or humanitarian protection and that to refuse you an extension would breach your rights under the ECHR; or
You are a victim of trafficking or slavery who has had a positive conclusive grounds decision from a competent authority of the national referral mechanism and you are seeking to extend beyond 30 months Discretionary Leave granted to you for reasons related to your trafficking or slavery.
Please ensure that you also complete and submit the relevant application form. You should only complete this form if you are seeking a fee waiver because you think you meet the published fee waiver policy. This will be because you are destitute, or because you would become destitute if you paid the fee (in respect of your own application or one or more of your dependants included in the application), or because there are exceptional circumstances relating to your financial circumstances which mean that you are unable to pay the fee for your application (or for that of one or more of your dependants). Definition of destitution You will be destitute if: a) b)
You do not have adequate accommodation or any means of obtaining it (whether or not your other essential living needs are met); or You have adequate accommodation or the means of obtaining it, but cannot meet your other essential living needs.
You must complete every section of this form.
You should not pay the Immigration Health Surcharge (IHS) if you are applying for a fee waiver. Applicants who are granted a fee waiver are not required to pay the IHS. 1 August 2017
However, applicants who are refused a fee waiver and who are required to pay a fee in order to validate their application, will be required to pay the IHS at that stage. If you wish to use a representative to assist you in completing this form, you should ensure that they are qualified to provide advice (see Find an immigration Adviser). The decision on whether you qualify for a fee waiver will be made on the basis of the information you provide in this form and the evidence submitted with it. It is your responsibility to provide sufficient information and evidence to demonstrate that you qualify for a fee waiver. You will need to provide documentary evidence with this fee waiver application to demonstrate your financial circumstances. The nature of this evidence will vary according to your individual circumstances, but some examples of relevant documents you may wish to include are listed below. Please note:
Documents from an official source must be on letter headed paper.
Letters from charities must show the registered charity number. Copies of documents such as bank and building society documents must be certified by the bank/financial institution.
If you live with a partner or with a family member or friend who supports you financially, you must provide evidence of their financial circumstances in addition to your own.
You must also provide evidence of the financial circumstances of all your dependants.
Please tick the boxes below to show which documents you are sending with your application: Bank statements covering the period of six months prior to the application Savings account statements covering the period of six months prior to the application Tenancy agreement or mortgage documents Utility and other relevant bills no more than three months old Letter confirming employment (the person writing should state their position in the company and contact details) Pay slips covering the period of six months prior to the application 2 August 2017
P60 End of Year Certificate: showing the amount of tax and National Insurance (NI) contributions paid in the tax year P45 Details of an employee leaving work: showing the amount of tax and NI contributions paid by the employee up to the date of leaving the employment Letters from a registered charity or Local Authority confirming you are in receipt of support from them Letters from any friends or family who are providing you with support explaining what support they are providing and if they are stopping that support why they are doing so Letters confirming you or your spouse/partner are in receipt of public funds Other documents – see box below. If you are including other documents (including any that you are asked to provide when answering the questions in the form), please give details in the box below:
This form is not an application for leave to remain. It is to enable a decision to be made on whether you qualify for a fee waiver for your separate application for leave to remain. If you qualify for a fee waiver, your application for leave to remain will then be considered. The granting of a fee waiver does not guarantee that your application for leave to remain will be successful. If you do not qualify for a fee waiver, your application may be invalid due to non-payment of the fee. If you applied in time, you will be advised in writing how you can make a valid application.
3 August 2017
Section 1 – basis of fee waiver application 1.1. Who is applying for a fee waiver? List below all the individuals who are included in your application for leave to remain in the UK (you will need to use the relevant form to make the application for leave to remain). Indicate which of them are also applying for a fee waiver. Main applicant name [ Dependant 1 name [ Dependant 2 name [ Dependant 3 name [ Dependant 4 name [ Dependant 5 name [ Dependant 6 name [
] fee waiver? [Y] [N] ] fee waiver? [Y] [N] ] fee waiver? [Y] [N] ] fee waiver? [Y] [N] ] fee waiver? [Y] [N] ] fee waiver? [Y] [N] ] fee waiver? [Y] [N]
1.1. Please tick the basis on which you and/or are applying for a fee waiver: I am destitute (see definition above). I am not destitute but I would become destitute if I paid the application fee Or (indicate which) I am not destitute but I would become destitute if I paid the fee for my own application and for the application for all of the dependants included in the application. I am not destitute and would not become destitute if I paid the application fee, but I have exceptional circumstances relating to my financial circumstances which mean I am unable to pay the fee for my own application and all of the dependants included in the application. Please provide an explanation below for why you have ticked the particular box above and continue on a separate sheet if necessary:
4 August 2017
Section 2 – Personal details
Title: Mr Gender:
Mrs Male
Miss
Ms
If other what is your title? Other
Female
Date of Birth (day/month/year): Your full name as in your passport or travel document: Surname or family name: Given name Any other name(s) by which you are or have been known: Nationality: Place of birth – town or city and country Passport, national identity card or travel document number: Home Office reference if you have one: National insurance number if you have one: BRP reference number (if you have one): 5 August 2017
What is your marital status:
Married
Single
Separated
Divorced
Civil partnership
Same Sex Partner
Widowed
Unmarried partner
Dissolved partnership
Surviving Civil partner
Personal details of your spouse/partner Is your spouse/partner currently in the UK?
Yes
No
Name of spouse/partner: Date of birth of your spouse/partner (day/month/year): Nationality of your spouse/partner: Personal details of your parents If you are a child aged under 18 please provide details of your parent(s). Name of parent 1: Date of birth of your parent (day/month/year): Nationality of your parent: Is this parent currently in the UK?
Yes
No
Name of parent 2: Date of birth of your parent (day/month/year): Nationality of your parent: Is this parent currently in the UK?
Yes
No
6 August 2017
Disability Do you consider yourself to be disabled?
Yes
No
Are any family members on whom you are dependent disabled? Are any of your dependent family members disabled?
Yes
Yes
No No
If yes, please provide full details of your or your dependent family member’s disability (and enclose relevant documentary evidence of this) and of any impact this has on your financial circumstances:
7 August 2017
Section 3 – Dependent family members Please complete this section for any children under the age of 18, or any other dependent family members, who are living with you in the UK. Please specify whether they are dependants on your application. Details of your dependent family member Name: Place of birth: Date of birth (day/month/year): Gender: Male
Female
Nationality: Home Office reference number (if known):
Details of your dependent family member Name: Place of birth: Date of birth (day/month/year): Gender: Male
Female
Nationality: Home Office reference number (if known):
If you have more than two dependent family members, please provide details on a separate sheet of paper.
8 August 2017
Section 4 – Your current accommodation 4.1 What address can we contact you at? House/Flat Number: Street Name: Town or City: County: Post Code: 4.2 Is this where you are currently living? Yes
No
4.3 If yes, when did you move into your current address?
If no, where are you currently living? Please provide the full address. If you are homeless please state this clearly. House/Flat Number: Street Name: Town or City: County: Post Code:
4.4 Please provide details of any previous UK addresses in the last five years: House/Flat Number: Street Name: Town or City: County: Post Code: Continue on a separate page if necessary. 4.5 Have you been asked to leave the accommodation in which you are currently living? Yes
No
4.6 If Yes, please provide details of why this is:
9 August 2017
Please provide documentary evidence such as a formal eviction notice. 4.7 Do you own or rent your home? Please specify: Own home Rent home Neither own nor rent home
4.8 If you do not own or rent your home who presently provides you with accommodation? Friend Relative Refuge Local Authority Registered charity Other Please provide a letter from your accommodation provider to confirm your living arrangements. If you live with a friend or relative, please provide a letter of support along with evidence of residence such as a utility bill in their name. If you have stated “other” please give details in the box below:
4.9 How many bedrooms are in the property?
4.10 How many rooms (not including kitchens/bathrooms/toilets) are in the property?
4.11 Who do you live with and what is their relationship to you? (List each person living with you, including all children)
10 August 2017
4.12 Do you pay for your accommodation costs or contribute towards them? Yes
No
If yes, please specify how much you pay, and how regularly you pay this (weekly/monthly):
4.13 Does anyone (including a Local Authority) support you financially or by providing your essential living needs such as food? If so, provide details below of who supports you, what form the support takes (cash, vouchers, food, etc.), how much support you are given and how often:
4.14 Are they able to continue supporting you? Yes
No
If you ticked the “no” box, please explain why.
Please provide documentary evidence of their financial circumstances such as annotated bank statements and payslips. 11 August 2017
4.15 Are you homeless tonight? Yes
No
4.16 Will you be homeless shortly? Yes
No
If yes, please explain why:
4.17 If yes, on what date will you become street homeless (day/month/year):
4.18 If you are homeless or at risk of homelessness, which organisations/charities/agencies have you approached for assistance? Please provide a recent letter from these sources. Section 5 – Your financial details Please note we require evidence of your finances, including bank statements, building society savings books or other formal documentation in support of your application for a fee waiver. This evidence should cover the six month period prior to your application being submitted. If you are being supported by a friend or relative, we require written evidence in the form of a letter confirming this, with formal documentation showing that person’s financial resources. If you are being supported by a registered charity or a Local Authority, we also require formal documentation to evidence this. Please provide full details of exactly what the support consists of, why you are eligible for such support and when the support began. 5.1 Have you received any support from friends since arriving in the UK? Yes
No
If yes, please provide details:
12 August 2017
5.2 Have you received any support from relatives since arriving in the UK? Yes
No
If yes, please provide details:
5.3 Are you able to borrow money for the application fee from family and/or friends? Yes
No
5.4 If you are already receiving financial support from family and/or friends, please provide documentary evidence to confirm whether you are able to borrow the application fee from them. 5.5 Have you received any support from a former partner? (This includes any child maintenance payments) Yes
No
If yes, please provide details:
5.6 Have you received any compensation or damages payments? Yes
No 13
August 2017
If yes, please provide details:
5.7 Do you have any of the following (you must tick any or all you have): Cash savings in the UK or overseas Bank or building society accounts in the UK or overseas (including accounts held by partner/dependent children) Number of accounts held by you: Number of accounts held by partner: Number of accounts held by dependent children: Investments Property in the UK Property outside the UK Land in the UK Land outside the UK Jewellery (except for wedding jewellery) TV, DVD player, electrical goods Car or other vehicle 5.8 Can you sell any of these non-cash assets? Yes
No
5.9 If you ticked yes, please explain why you have not sold the asset. If you ticked no, please explain why you cannot sell the asset.
14 August 2017
5.10 What is the value of each of the assets you ticked in question 5.7?
Please specify the relevant currency:
5.11 If you have money or investments held in a bank account in the UK or overseas, please provide the name of the bank/building society/other financial institution in which the funds are held and the name of the country in which the account is held:
You must list each account held (including accounts held in the names of any dependent children) and provide statements covering the period of six months prior to the application being submitted for each account held. 5.12 If the bank account(s) held is not in the UK, are you able to access it from within the UK? Yes
No
If no, please explain why not:
5.13 Please list any other material or monetary assets you own, and their approximate value:
15 August 2017
5.14 Are you currently working in the UK, or do you have a confirmed offer of employment? Yes
No
5.15 If you ticked yes above because you are working in the UK, please provide details of the nature of the employment or self-employment:
5.16 If you ticked yes above because you are working in the UK, please provide details of your employment income and how frequently it is paid (weekly/monthly/annually):
Please provide documentary evidence of all employment income in the period of six months prior to the application being submitted, such as payslips, bank statements and your most recent P60/P45.
5.17 If you ticked yes above because you have a confirmed job offer, please provide details here, including the amount of employment income you expect to earn, and how frequently this will be paid, and when the employment will begin:
16 August 2017
Section 6 – Public funds 6.1 Do you receive any of the following public funds? You must declare any or all of the following you receive:
Attendance allowance Carer’s allowance Child benefit Child tax credit Contribution-based jobseeker’s allowance Contribution-based employment and support allowance Council tax support Disability living allowance Housing benefit Housing and homelessness assistance Incapacity benefit Income-based jobseeker’s allowance Income-related employment and support allowance Income support Personal independence payment Pension credit Severe disablement allowance Social fund payment State pension credit Universal credit Working tax credit
Yes
No
If yes, please state for each public fund you are receiving: Type of benefit or allowance
Date you started receiving it (day/month/year)
How often do you receive it?
How much do you receive?
Please continue on a separate sheet if necessary.
17 August 2017
Section 7 – Spouse/partner/parent financial details Please note: you need only provide details of your parents if you are living with one or both of them and they are currently supporting you, or if you are a child aged under 18. 7.1 Is your spouse/partner or either of your parents currently employed or working in the UK, or do they have a confirmed offer of employment? Yes
No
Please provide documentary evidence of your spouse/partner/parents’ employment income in the period of six months prior to the application being submitted, such as payslips, bank statements and their most recent P60/P45 7.2 If you ticked yes above because your spouse/partner or either of your parents is working in the UK, please provide details of the nature of the employment or selfemployment:
7.3 If you ticked yes above because your spouse/partner or either of your parents is working in the UK, please provide details of their employment income and how frequently it is paid (weekly/monthly/annually):
7.4 If you ticked yes above because your spouse/partner or either of your parents has a confirmed job offer, please provide details here, including the amount of employment income they expect to earn, and how frequently this will be paid, and when the employment will begin.
18 August 2017
7.5 Does your spouse/partner or either of your parents have any of the following assets (you must tick any or all of the assets they have): Cash savings in the UK or overseas Bank or building society accounts in the UK or overseas Number of accounts held by spouse/partner/parents: Investments Property in the UK Property outside of the UK Land in the UK Land outside the UK Jewellery (except for wedding jewellery) TV, DVD player, electrical goods Car or other vehicle Can your spouse/partner or either of your parents sell any of these non-cash assets? Yes
No
7.6 If you ticked yes, please explain why they have not sold the asset. If you ticked no, please explain why they cannot sell the asset.
7.7 What is the value of each of the assets belonging to your spouse/partner or either of your parents that you ticked in question 7.5? 19 August 2017
Please specify the relevant currency:
7.8 If your spouse/partner or either of your parents has money or investments held in a bank account within the UK or overseas, please provide name of bank or building society/other in which the asset is held and the name of the country where these assets are:
7.9 If the bank accounts held are not in the UK, is your spouse/partner or either of your parents able to access them from within the UK? Yes
No
7.10 Does your spouse/partner or either of your parents receive any public funds? Yes No Question 6.1 has a list of what constitutes public funds. Please refer to this list if you are unsure. If Yes, please state for each public fund your spouse/partner is receiving: Type of benefit or allowance
Date your spouse/partner started receiving it (day/month/year)
How often does he or she receive it?
How much does he or she receive?
Please continue on a separate sheet if necessary.
Section 8 – Additional Information 20 August 2017
Please provide any additional information that you would like us to take into account in determining whether you qualify for a fee waiver. Please continue on a separate sheet if necessary.
21 August 2017
Section 9 – Household income and outgoings Please complete the following table with details of your household monthly income and outgoings. Your household monthly income should be based on the average monthly income your household received over the period of six months prior to the application. Your household includes you, your partner, your dependants and any other persons with whom you live and on whom you depend for financial support. Your monthly outgoings should be an average of your monthly outgoings based on the period of six months prior to the application. The information provided below should be supported by documentary evidence submitted with your application. A breakdown of your monthly income is as follows:
Wages (net wages after deductions):
A breakdown of your monthly outgoings is as follows:
£
Overtime (net after deductions):
£
State Benefits:
£
Tax (if self-employed)
£
National Insurance (if self-employed)
£
Rent/Mortgage
£
Car/Travel Expenses
£
Pension (Private/State):
£
Gas
£
Drawings from business:
£
Electricity
£
Profit from business:
£
Water
£
Income from trust:
£
Food
£
Clothing
£
Dividends from shares:
£ Mobile Phone
£
Interest from savings:
£ Telephone/Broadband
£
Assistance from family/friends:
£ Sky/Cable TV
£
Insurance
£
Assistance from Local Authority: Other (please specify):
£ £
Gym Membership £ Other (specify) lots of potential outgoings not listed here Total: £
Total: £
Please note: All figures provided on this form must be supported with evidence/documentation. Signed
Date: 22
August 2017
Declaration You must read the declaration below and sign it. This must 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 is mandatory for the declaration to be signed. Where one or more dependants of the main applicant are applying for a fee waiver, you must photocopy this declaration and a separate copy must be signed by each person applying for a fee waiver. Please note that this application will be rejected as invalid if it is not signed as specified above. I hereby apply for a fee waiver for myself. The information given by or about me in this form is complete and is true to the best of my knowledge. I confirm that if, before this application for a fee waiver is decided, there is a material change in my or my dependants’ circumstances or new information relevant to this application for a fee waiver becomes available, I will inform the Home Office. I understand that all information provided by me to the Home Office will be treated in confidence; that it may be disclosed to other government departments, agencies, local authorities, the police, foreign governments and other bodies for immigration purposes or to enable them to perform their functions; and that, if such bodies provide the Home Office with any information about me, which may be relevant for immigration purposes, it may be used in reaching a decision on my application. I understand that my details may 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 GOV.UK. I understand that documents provided in support of this application for a fee waiver will be checked for authenticity; and that false documents will be retained and may result in my application being refused and in my prosecution. I understand that the Home Office may also use the information provided by me for training purposes.
Signature: Print Name: 23 August 2017
Date:
Any friend, relative or other party whom the applicant has stated will provide financial support and/or is a joint customer with the applicant with a bank or utility company must ensure that they have also completed the consent for verification checks declaration which is included in the relevant leave to remain application form.
24 August 2017
Checklist: Have you completed all the questions on this form? Have you enclosed all documentary evidence required by this form? Have you enclosed a fully completed application form for leave to remain? (If not, or if you have enclosed the wrong form, your application may be rejected).
25 August 2017
