Appendix 1 FLR(O)Request for Fee Exemption from applicant who is destitute seeking to apply for leave to remain on the basis of Article 8 right to respect for family or private life under Appendix FM or paragraph 276ADEYou should only complete this form if you are seeking a fee exemption because you are destitute and so are unable to pay the fee for your leave to remain application form FLR(O). Definition of destitutionYou will only be considered to be destitute if:a) You do not have adequate accommodation or any means of obtaining it (whether ornot your other essential living needs are met); orb) You have adequate accommodation or the means of obtaining it, but cannot meetyour other essential living needs.Please ensure that you also complete and submit Form FLR (O) 04/2013.If you wish to use a representative to assist you in completing this form, they should be registered with the Law Society or the Office of the Immigration Services Commissioner (OISC). You can also refer to the Immigration Enquiry Bureau (IEB) on 0870 606 7766 or consult our website at: .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 under ECHR Article 8 using form FLR(O); and∙You are destitute, and so are unable to pay the fee for your leave to remain application form FLR(O).You must complete every section of this form.The decision on whether you qualify for a fee exemption will be made on the basis of the information you provide in this form and the evidence submitted with it. It is up to you to provide sufficient information and evidence to show that you are destitute.12You should not complete this form if you applying for leave to remain in the UK on the basis of family or private life under ECHR Article 8 using form FLR(O) and are not destitute. In that situation you should use form FLR(O) and not submit this Appendix 1.You will need to provide full documentary evidence along with this fee exemptionapplication to demonstrate your financial circumstances. The nature of this evidence may vary according to your individual circumstances, but some examples of relevant documents you may wish to include are stated below. Documents should be on letter headed paper from an official source. Letters from charities should show the registered charity number. Copies of bank and savings documents should be certified by the bank/financial institution. Please tick the boxes below to show which documents you are enclosing:Savings account statementsTenancy agreement or documents relating to your mortgage Utility and other relevant billsLetter confirming employment (the person writing should state their position in the company and contact details)Pay slips P60P45Letters from a charity or Local Authority confirming you are in receipt of support Letters from any friends or family who are providing you with support Letters confirming you or your spouse/partner are in receipt of public fundsOther documents –please specify what they are.If you are including other documents please give details in the box below:This isnot an application for leave to remain on the basis of Article 8 family or private life grounds. It is an assessment as to whether we consider you to be destitute in order towaive the application fee for Form FLR(O). If you are seeking a fee exemption you should submit your FLR(O) form and Appendix 1 request for fee exemption form at the same time. The FLR(O) may require you to submit additional documentary evidence.If you are granted a fee exemption, this does not guarantee that your application for leave to remain will be successful.If you decide not to continue with your application, you must contact us immediately. Section 1 - Biometric residence permits (BRP)If you qualify for a fee exemption because you are destitute, we will contact you and provide you with information about enrolling your biometric data without having to pay a fee. Failure to provide your biometric data will result in your application being rejected.If you do not qualify for a fee exemption your application will be rejected. If you wish to apply for leave to remain on the basis of your family or private life you will need to re-submit your FLR(O) form, with the relevant fee.Section 2 – Your personal details3Section 3 – DependantsPlease complete this section for children under the age of 18 years living with you in the UK4If you have more than 3 dependants please provide details on a separate sheet of paper.5REASONS WHY YOU ARE DESTITUTE:Note: You should demonstrate in your answers to questions 4.1 to 7.4 below, whether you have adequate accommodation or the means of obtaining it, and if you have adequate accommodation, whether you cannot meet your other essential living needs. If you have been without support from a third party for some time you will be expected to explain how you have supported yourself during this period and provide evidence.Please answer all the questions below. If you do not fully complete the form we may reject your application.Section 4 – Your current accommodation circumstances4.1 What address can we contact you at?House/Flat NumberStreet NameTown or CityCountyPost CodeNo4.3 If yes, when did you move into your current address?If no, where are you currently living? Please provide the full address unless you are homeless.House/Flat NumberStreet NameTown or CityCountyPost Code4.4 Please provide details of any previous UK addresses:House/Flat NumberStreet NameTown or CityCountyPost CodeContinue on a separate page if necessary.674.5 Have you been asked to leave the accommodation in which you are currently living?No4.6 If Yes, please provide details of why this is:4.7 Do you own or rent your home? Please specify:Own homeRent home4.8 If you do not own or rent your home who presently provides you with accommodation?FriendRelativeRefugeLocal AuthorityCharitable organisationOtherIf you have stated “other” please give details in the box below: 4.9 Who do you live with and what is their relationship to you?If Yes, specify how much you pay, and how regularly you pay this (weekly/monthly):84.11 Does anyone support you financially or by providing your essential living needs such as food? If so, who?4.12 Are they able to continue supporting you? If not, please explain why in the box at Section 8.4.13 Are you homeless tonight?4.14If Yes, please explain why:4.15 If yes, on what date will you become street homeless? (day/month/year)Section 5 – Your financial detailsPlease 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 Exemption. 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 th at person’s financial resources. If you are beingsupported by a charity or other organisation, including a Local Authority, we also require formal documentation to evidence this. Please provide full details of exactly what the support entails, why you are eligible for such support and when the support began.95.3 Do you have any of the following material assets(You must tick any or all of the assets you have)∙ Cash savings∙ Property in the UK∙ Property outside of the UK∙ Land in the UK∙ Land outside the UK∙ Valuable jewellery∙ TV, DVD player, electrical goods∙ Car or vehicle5.5 What is the value of all/each of the above assets?Please specify the relevant currency:5.6 Please indicate any other material assets.5.7 Do you have any of the following monetary assets?∙ Cash held in the UK or overseas∙ Savings/investments in the UK or overseas105.8 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:5.9 What is the value of your savings or investments?Please specify the relevant currency:5.11 Please list any other monetary assets:Section 6 – Public Funds6.1 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 benefit∙ Disability living allowance ∙ Housing benefit∙ Housing and Homelessness assistance ∙ Incapacity Benefit∙ Income based job seekers allowance∙ Income related employment support allowance ∙ Income support11∙Personal independence payment ∙Pension credit ∙Severe disablement allowance ∙Social fund payment ∙State pension credit ∙ Working tax creditIf Yes, please state for each public fund you are receiving:Section 7 – Spouse/partner financial detailsIf Yes, please provide details of the nature of their employment and their salary, including what income they receive in each relevant period (weekly/monthly/annual)Employment:Salary:If Yes, please provide details and value of assets:Please specify the relevant currency:12If Yes, please provide details and value of savings or investments:Please specify the relevant currency:NoIf Yes, please state for each public fund your spouse/partner is receiving:Please continue on a separate sheet if necessary.Section 8 – Additional InformationPlease provide any additional information that you feel we should take into account in determining whether you should be exempt from paying a fee for the FLR(O)DeclarationI can confirm that I have included all the necessary information and evidence that supports this application for a Fee Exemption.I am aware that it is an offence under the Immigration Act 1971, as amended bythe Immigration and Asylum Act 1999 and the Nationality, Immigration and Asylum Act 2002, to make to a person acting in execution of any of those Acts a statement or representation which I know to be false or do not believe to be true, or to obtain or to seek to obtain leave to remain in the United Kingdom by means which include deception.I confirm that I have provided full and complete details of my financial situation and that of my spouse/partner, and confirm that the information provided is accurate and truthful. I will notify the Home Office if my circumstances change whilst my application is being considered.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 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 following this application.I understand that my details may in certain circumstances be passed to fraud prevention agencies to prevent and detect fraud and money laundering. I also understand that such agencies may provide the Home Office with information about me. Further details explaining when information may be passed to or from fraud prevention agencies and how that information can be obtained from the Home Office website at:.I have completed Section 9 of FLR(O) which gives consent for the Home Office to request verification checks of the documents I have supplied to show that I am destitute in order to make an application on Form FLR(O) without paying a fee.Signature:Print Name:Date:Checklist:Have you fully completed this form?Have you enclosed full documentary evidence required by this form?Have you also enclosed a fully completed FLR (O) 04/2013 form? (If not, or if youhave enclosed the wrong form, your application will be rejected.)14。