Tier 1, 2 or 5

PBS
Dependant
version 04/2014

Application for a Grant of Leave and

Biometric Immigration Document as a
Tier 1, 2 o r 5 Dependant
In accordance with paragraph 34 of the Immigration Rules, this form is
specified for applications made on or after 6 April 2014. Please check on the
website at https://www.gov.uk/government/publications/application-for-a-
grant-of-leave-tier-1-2-or-5-pbs-dependant 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

Please post or courier your application to:

Postal address: Postal address: Courier address:

Home Office Home Office Home Office

Tier 1 Dependants Tier 2 or 5 Tier 1, 2 or 5 Dependants
Dependants
PO Box 496 Millburngate House This form is
PO Box 506 specified for
Durham Millburngate
Durham applications
DH99 1WQ Durham
made on or after
DH99 1WB
DH97 1PA 6 April 2014
 Tier 1, 2 or 5 Dependant application Form

Intentionally Blank

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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) standard £1,607

Tier 1 – (Entrepreneur, Investor, Exceptional Talent) £1,093

Tier 1 – Graduate Entrepreneur standard £422

Tier 1 – Exceptional Talent Extension £1,093

Tier 1 - Post Study Work standard £324

Tier 2 General, ICT Long Term Staff, Sport & MOR - up to 3 years leave to
£601
remain
Tier 2 ICT Short Term Staff, Graduate Trainee or Skills Transfer £428

Tier 2 General, ICT Long Term Staff – over 3 years leave to remain £1,202

Tier 2 Shortage Occupations - up to 3 years £428

Tier 2 Shortage Occupations - over 3 years £856

Tier 5 – standard £208

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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

Day Month Year

A2.5 Main Applicant’s full name

A2.6 Main Applicant’s date of birth

Day Month Year

A2.7 Please select the method of payment from the list below
United Kingdom postal order (payable to Debit or credit card -
‘Home Office’) - go to part B go to question A2.9
Cheque (payable to ‘Home Office’) - go Banker’s draft - go to
to question A2.8 question A2.8
A2.8 Paying by cheque - please give cheque details below
Account number Sort code Cheque number

A2.9 Paying by card

Which card are you using for Visa / MasterCard Delta Maestro/
payment? Please tick a box and Electron /Amex Solo
complete A2.10 - A2.14 below.
A2.10 Name on
card
A2.11 Card
number
Valid from Expiry date 3 digit number Security No - CVV
A2.12 Card (or 4 digit Issue
details number for No.
(where
Amex) available)
A2.13 Cardholder’s signature A2.14 Date
Day Month Year

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 Tier 1, 2 or 5 Dependant application Form

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

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 Tier 1, 2 or 5 Dependant application Form
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 D D M M Y Y Y Y

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

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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

Now go to Section C

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Section C – Details about the PBS MAIN APPLICANT you are dependant on

In this section you will asked questions about the PBS main applicant that you are dependant on.

C1; What is the full name of the PBS main applicant you are dependant 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 dependant on, as stated in
their passport or travel document?
D D M M Y Y Y Y

C3; What is the nationality of the PBS main applicant you are dependant 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 dependant on? (ht)

C5; Have you previously been granted leave to

Yes No
enter or remain as the dependant of the PBS main
applicant on which you are dependant?

Now go to Section D

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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 representative’s 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

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D7; Please provide your representative’s contact details:
Work telephone number
Mobile telephone number
Email address line 1
Email address line 2
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 don’t know

Now go to Section E

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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 D M M Y Y Y Y

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

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E7; Please provide the following contact details:

Work telephone number
Home telephone number
Mobile telephone number
Fax number

Email address line 1

Email address line 2

E8; Please tick to indicate what your preferred contact telephone number is:
Work
Home
Mobile

Now go to Section F

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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

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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 What What is What is What is Is the If the passport or
is your is the the issue the expiry the place passport travel document is
current nation- date? date? of issue? or travel not enclosed, please
passport ality document indicate why:
or travel on the enclosed?
document passport?
number?
Yes - Lost - go to G2
go to G4
Stolen - go to
G3
No -
go to next Expired and
column returned
to national
authorities - go
to G4

Already with
The Home
Office - go to
G4

G2; Please explain how you lost your passport: (ht)

G3; Please provide the following details: (ht)

What was the Police What was the crime Which police station What date was this
report number? reference number? was this reported at? reported to the Police
on?

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

G5; Please provide the following details: (ht)

Previous Passport or Travel Document
What is the What is the What is What is What is the Is the If the passport or
passport nationality the issue the expiry place of passport travel document is
or travel on the date? date? issue? or travel not enclosed, please
document passport? document indicate why:
number? enclosed?

Yes - Lost - go to G6
go to
Section H
Stolen - go to
G7
No - Expired and
returned
go to next
to national
column
authorities go
to Section H
Already with
The Home
Office

G6; Please explain how you lost your passport: (ht)

G7; Please provide the following details: (ht)

What was the Police What was the crime Which police station What date was this
report number? reference number? was this reported at? reported to the Police
on?

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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 What is Is your BRP If the BRP is not
BRP number? nationality on the issue the expiry enclosed enclosed please
the BRP? date? date? with this indicate why:
application?
Yes - go to Lost - go to H3
H7

Stolen - to go
H4
No - go
to next
Expired and
column
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 What was the crime Which police station What date was this
report number? reference number? was this reported at? reported to the Police
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 D M M Y Y Y Y

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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 D D M M Y Y Y Y

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

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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 D M M Y Y Y Y

I4; What date did you move from this address? (ht)
D D M M Y Y Y Y
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 D M M Y Y Y Y

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I8; What date did you move from this address?
D D M M Y Y Y Y

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

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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 D M M Y Y Y Y

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:

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J9; Date of the judgement or civil penalty
D D M M Y Y Y Y

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

J16; Please provide details:

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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

J18; Please provide details:

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

J20; Please provide details:

Now go to Section K

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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 D M M Y Y Y Y

K9; What date was your visa or entry clearance valid to? (ht)
D D M M Y Y Y Y

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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

K17; Please provide details: (ht)

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

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K19; Please provide details: (ht)

K20; Have you ever been removed, required to leave or deported from the UK? (ht)
Yes go to K21 No go K22

K21; Please provide details: (ht)

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

K23; Please provide details: (ht)

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

K25; Please provide details: (ht)

Now go to Section L

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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 Carer’s 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

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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

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 Tier 1, 2 or 5 Dependant application Form
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 2 (General) - go to M3
Tier 2 (Intra Company Transfers) - go to M3
Tier 2 (Minister of Religion) - go to M3
Tier 2 (Sportsperson) - go to M3
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

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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 2 (General) - go to M11
Tier 2 (Intra Company Transfers) - go to M11
Tier 2 (Minister of Religion) - go to M11
Tier 2 (Sportsperson) - go to M11
Tier 5 (Temporary Worker) - All categories - go to M11

M6; Has the PBS main applicant’s 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 £1800 in available funds.
Go to M13
M9; Please tick the box below:
I can confirm that I am providing evidence of having £600 in available funds.
Go to M13
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 £1200 in available funds - go to M13
Where PBS migrant has been in the UK more than 12 months
I am providing evidence of having £600 in available funds - go to M13

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 Tier 1, 2 or 5 Dependant application Form

M11; How are you able to demonstrate that you have sufficient funds available to you?
My maintenance has been certified by an A-rated sponsor (Tier 2 dependants
only)- go to M12

I am providing evidence of having £600 in available funds - go to M13

M12; As your maintenance is being certified by the Tier 2 sponsor, please tick one of the
following boxes:

I confirm that the A-rated sponsor has certified maintenance for me on the
main applicant’s Certificate of Sponsorship (CoS)
I confirm that the A-rated sponsor has certified maintenance for me in a
letter
M13; 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

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 Tier 1, 2 or 5 Dependant application Form

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
dependant upon.

N1; What is your relationship to the PBS main applicant that you are dependant 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

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 Tier 1, 2 or 5 Dependant application Form
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 dependant upon your sole surviving parent?
Yes go to the next section No go to N14

N14; Has the PBS main applicant you are dependant 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

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 Tier 1, 2 or 5 Dependant application Form
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 D M M Y Y Y Y

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 Tier 1, 2 or 5 Dependant application Form

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 representative’s 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 D M M Y Y Y Y

Name of your organisation:

Your position within the organisation:

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 Tier 1, 2 or 5 Dependant application Form

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.

How How
A. Type of document B. Listed items
many? many?

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

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