DATE STAMP

Departme nt of Justi
DEPARTMENT OFc Je, Equality
USTICE and Law Reform
AND EQUALITY (FOR OFFICE USE ONLY)
Irish INaturalis
RISH ation &Immigration
NATURALISATION & IMMIGRATION Service
SERVICE

Application for Immigration Permission De Facto 1 2017

for a De Facto Partner

This form is to be completed by the De Facto partner applying for permission to remain in the State on the basis of De Facto Partnership
with an Irish National or legal resident in Ireland on a Stamp 1, 4 or 5 (the Sponsor), as set out in Policy Document on Non-
EEA Family Reunification available at INIS website http://inis.gov.ie.
This form should be completed by a person who is unable to register with the Garda National Immigration Bureau as the de fact o partner of
an Irish National or legal resident on stamp 1,4 or 5.

This form must be completed in BLOCK CAPITALS. Where indicated, please place a tick ( ) in the appropriate box.

To be eligible to apply for De Facto Partnership Immigration Permission, you must meet the following criteria:
1. The Applicant and the Sponsor must be in the State when the application is made.
2. The Applicant must be legal in the State.
3. The Applicant and the Sponsor must be cohabiting together for at least 1 year prior to submitting the application.

All sections must be completed as required. The three Statutory Declarations in Section 8 must be signed before a relevant authority.
Incomplete applications cannot be processed and will be returned.

Please note that certain documents are required to be submitted with this form. Please refer to the checklist in Section 9. Please submit
photocopies of documents unless otherwise requested as it is not possible to return any documentation that is submitted with your
application.

If you are presently unable to provide any of the information or details requested in any of the relevant sections, please explain the
reasons in Section 7 of application form.

A decision will be taken on the application no later than six months from the date of receipt of a fully completed application form together
with the relevant supporting documentation.

While your application is being processed the onus is on you, the applicant, to advise this office of any change in your circumstances
(including change of residence or change in activities of the Sponsor). You must submit new supporting documentation as appropriate.

Do not submit the application form without ensuring that you are eligible for the scheme.

Do not submit the application without properly completing the Statutory Declarations and enclosing all of the required documentation
specified below in the document checklist. If documents are missing or if the form is not fully completed, your application may be refused.

Section 1 Applicant Details

1.1 Surname / Family name (as in passport)

1.2 Forename(s) (as in passport)

1.3 Other name(s) (maiden name, name at birth, and any other names by which you are or have been known)

1.4 Date of Birth 1.5 Gender (please tick) 1.6 Marital Status

Day Month Year Male Female

1.7 Country of Birth

1.8 Nationality

De Facto Partnership Form - Page 1 of 12

1.9 Private Medical insurance (please tick)
Yes No

1.10 Current Residential Address in Ireland

1.11 Contact Telephone Number

1.12 Email Address

1.13 Passport Number

1.14 INIS Person ID Number (if applicable)

1.15 Old Department Reference Number (if applicable)

6 9
1.16 GNIB Registration Number (if applicable)

Section 2 Relationship History

2.1 Date and Place of Meeting

2.2 Date of Commencement of Relationship

2.3 Date of Commencement of Cohabitation

2.4 Relationship History and Future Plans, e.g. Marriage.

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 Section 3 Applicants Immigration History

3.1 Date of arrival in the State

Day Month Year

3.2 Place of arrival in the State

3.3 Status on arrival in the state (please tick)

Asylum-seeker Visitor / (C-Visitor Visa)

Student Employment Permit or Green Card Permit

De Facto Partner of Irish National / (D-Join Visa) Other

If "Other", please give details:

3.4 Have you previously resided in the State? Yes No

(If "yes", please give details)

3.5 Have you ever been convicted of any criminal offence in the State or abroad? Yes No
(If "yes", please give details)

3.6 Are there any criminal charges pending against you in the State or
Yes No
abroad?
(If "yes", please give details)

3.7 Have you ever been deported from the State? Yes No

3.8 Have you submitted a Police Clearance for any Country in which you have resided
Yes No
for the past 5 years?
3.9 Have you applied for De Facto Partner Permission before? If you answered yes,
please give: Date of Application and Application Reference Number. Yes No

Section 4 Details of Partner

4.1 Surname / Family name (as in passport)

4.2 Forename(s) (as in passport)

4.3 Other name(s) (maiden name, name at birth, and any other names by which you are or have been known)

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4.4 Current Residential Address in Ireland

4.5 Date of Birth 4.6 Gender (please tick) 4.7 Marital Status

Day Month Year Male Female

4.8 PPS Number:

4.9 Country of Birth 4.10 Date of arrival in the State (if applicable)

Day Month Year

4.11 Passport Number 4.12 Present Nationality

4.13 Department Reference Number (if applicable) 4.14 Contact Telephone Number

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4.15 Email Address

Section 5 Current activity of Partner in the State

5.1 Type of activity (please tick)

(A) Employment (B) Self-employment (C) Study

(D) Involuntary unemployment (E) Residing with sufficient resources

Please fill out Parts (A - E) below as applicable to the current activity of the Partner (Sponsor) in the State.
NOTE: it is important to provide accurate contact details for employer/college as they may be contacted to verify the information provided.

(A) Employment (or vocational training)

5.2 Name of employer

5.3 Employer's contact telephone number 5.4 Number of hours worked each week

5.5 Employers email address

5.6 Address of workplace

(B) Self-employment
5.7 Name of business

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5.8 Nature of business

5.9 Address of business

5.10 Business telephone number

(C) Study
5.11 Name of College

5.12 Address of College

5.13 College telephone number

(D) Involuntary unemployment

5.14 Name of last previous employer

5.15 Address of last previous employer

5.16 Last previous employer's contact telephone number 5.17 Date employment ceased

Day Month Year

5.18 Total duration of all previous employment in the State 5.19 Registered as job-seeker (please tick as applicable)

Years Months Employment Services Department of Social Protection

(E) Residing with sufficient resources

5.20 Details of financial resources

5.21 Private Medical insurance (please tick)

Yes No

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 Section 6 Dependent Children

6.1 If the applicant has dependent children who intend to live with the Applicant and Sponsor in Ireland, please provide:
1. Copies of Birth Certificate(s) and passport(s) of the child(ren).
2. Evidence that the Applicant is the childs legal guardian and
3. Evidence that the Applicant has sole custody and guardianship of the child(ren)
4. Evidence that the Applicant and any dependent child(ren) are covered by private medical insurance.

Section 7 Additional Information

Please provide any other information that you consider relevant to this application. Please be advised that if you
are unable to provide any of the information or details requested within this form then please provide an
explanation indicating the reasons for this.

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Section 8 Statutory Declarations

Statutory Declaration: Applicant

To be signed before a solicitor, commissioner of oaths or peace commissioner

I hereby apply for residence permission for myself. I make the following declaration under the Statutory Declaration Act
1938.

The information I have given is complete and is true to the best of my knowledge. I confirm that if, before my application
is decided, there is a material change in my circumstances or new information relevant to this application becomes
available, I will inform the De facto Partnership Unit of the Department of Justice and Equality in writing immediately. I
understand that any false or misleading information or fraudulent supporting documentation submitted will result in the
refusal of this application.

I understand that a person who intentionally makes a false statement in a statutory declaration is guilty of an offence
under Section 6 of the Statutory Declarations Act 1938 and shall be liable on summary conviction to a fine or, at the
discretion of the court, to imprisonment.

I understand that, under Section 8 of the Immigration Act 2003 the data in this application may be disclosed to other Irish
Government Departments, Government Agencies and/or An Garda Sochna for purposes connected with this or any other
application. I consent to INIS making enquiries to confirm any of the details or documents provided by me in this
application, including my participation in an interview process.

Signed by Applicant Date

Day Month Year

Declared before me ______________________ [name in capitals] a [solicitor] [notary public] [commissioner for oaths]
[peace commissioner] to take and receive statutory declarations by

Applicant
name

[who is personally known to me]

or
[whose identity has been established to me before the taking of this Declaration by the production to me of passports

Applicant passport No.______________ Date of issue ____________ Issuing Authority ________________________

Signed by [solicitor] [notary public]

[commissioner for oaths] [peace commissioner] Date

Day Month Year

Stamped by relevant Authority

[solicitor] [notary public] [commissioner for oaths]
[peace commissioner]

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 Statutory Declaration: Partner (Sponsor)

To be signed before a solicitor, commissioner of oaths or peace commissioner

The information given in this form is complete and is true to the best of my knowledge. I confirm that if, before the
application is decided, there is a material change in my circumstances or new information relevant to this application
becomes available, I will inform the DeFacto Partnership Unit of the Department of Justice and Equality in writing
immediately. I understand that any false or misleading information or fraudulent supporting documentation submitted will
result in the refusal of this application.

I understand that a person who intentionally makes a false statement in a statutory declaration is guilty of an offence
under Section 6 of the Statutory Declarations Act 1938 and shall be liable on summary conviction to a fine or, at the
discretion of the court, to imprisonment.

I understand that, under Section 8 of the Immigration Act 2003 the data in this application may be disclosed to other Irish
Government Departments, Government Agencies and/or An Garda Sochna for purposes connected with this or any other
application. I consent to INIS making enquiries to confirm any of the details or documents provided by me in this
application, including my participation in an interview process.

Signature of Sponsor Date

Day Month Year

by Declared before me ________________________________ [name in capitals] a [solicitor] [notary public]

[commissioner for oaths] [peace commissioner] to take and receive statutory declarations

Name of Sponsor

[who is personally known to me]

or
[whose identity has been established to me before the taking of this Declaration by the production to me of passports

Sponsor passport No. __________________ Date of issue ____________ issuing Authority _____________________

Signed by [solicitor] [notary public]

[commissioner for oaths] [peace commissioner] Date

Day Month Year

Stamped by relevant Authority

[solicitor] [notary public]
[commissioner for oaths] [peace commissioner]

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 Statutory Declaration: Supporting Witness

To be signed before a solicitor, commissioner of oaths or peace commissioner

Name

Address

Applicants name

1. How long have you known this person

Name of Applicants partner

2. How long have you known this person

3. State how you know the applicant and the applicants partner and indicate how often you have been in
contact with them

4. State whether you believe the relationship of the applicant and his/her partner to be genuine and continuing,
and give your reasons for your belief.

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5. State any reasons you wish to add in support of the application.

I declare that the information I have given is complete and is true to the best of my knowledge. I understand that any false
or misleading information or fraudulent supporting documentation submitted will result in the refusal of this application.

I understand that a person who intentionally makes a false statement in a statutory declaration is guilty of an offence
under Section 6 of the Statutory Declarations Act 1938 and shall be liable on summary conviction to a fine or, at the
discretion of the court, to imprisonment.

Signature of Supporting Witness Date

Day Month Year

Declared before me ________________________________ [name in capitals] a [solicitor] [notary public]

[commissioner for oaths] [peace commissioner] to take and receive statutory declarations

Name of Supporting Witness

[who is personally known to me]

or
[whose identity has been established to me before the taking of this Declaration by the production to me of passports

Witness passport No. __________________ Date of issue ____________ issuing Authority _____________________

Signed by [solicitor] [notary public]

[commissioner for oaths] [peace commissioner] Date

Day Month Year

Stamped by relevant Authority

[solicitor] [notary public]
[commissioner for oaths] [peace commissioner]

De Facto Partnership Form - Page 10 of 12

 Section 9 Document Checklist
Please provide photocopies of the documents requested below. It is advisable to send your application form and
documentation by registered post
Evidence of identity

Passport of applicant Passport of Sponsor

Evidence of relationship of applicant with Sponsor

Please provide supporting evidence of your relationship, i.e. A history of the relationship when the partners met and when the
relationship began
Evidence of cohabitation of one year or Evidence of financial inter-dependence, Financial Statements covering
more (in Ireland or another country). i.e.: Joint accounts, Joint Purchases. the previous 6 months.
(For Civil Partner)

Evidence of contact ie. Letters, e-mails, facebook etc. Detailed relationship history incl time spent together ie.
Photographs, Air Tickets etc.

Evidence of residence in the State

If Renting
Letter from landlord/agency, rental contract, rent book or tenancy agreement (dated)

Letters of Registration of Tenancy from the Residential Tenancies Board (dated)

Utility bills in the names of both the applicant and the Sponsor (dated)
Proof of rent paid, e.g. bank statements (dated)

If Home-owning

Letter from mortgage provider, local authority or County Council (dated)

Title or deeds (as applicable)

Utility bills in the names of both the applicant and the Sponsor, also bank statement showing mortgage payments
(dated)

If other please state, e.g. Living with family member

If living with a family member, please note that the parent/family member will be required to complete and sign the
Statutory Declaration for a supporting witness before a relevant authority (see Section 8)

Evidence of current activity of Sponsor in the State

Please provide supporting documents for the current activity as per Section 5, Parts (A - E).
(A) Employment
Current letter from employer setting out terms, conditions and hours of employment
AND/OR Signed contract of employment
Two recent payslips & previous 3 years P60s

Bank statements for you and your partner for the last six months

(B) Self-employment
Agreed Tax Assessment from the Revenue Commissioner for the last financial year (if applicable)
OR Letter of Registration for Self-Assessment (Income Tax) from the Revenue Commissioner
Bank statements of the business for the last six months

Bank statements for you and your partner for the last six months

(C) Study
Letter from college/course provider including course description, start date and completion date

Evidence of Private Medical Insurance (for Sponsor and applicant )

Bank statements AND/OR other evidence of financial resources

(D) Involuntary Unemployment

Letter from Department of Social Protection with details of benefit claims

Letter from Employment Services Office acknowledging registration as a jobseeker

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 Letter from previous employer outlining circumstances of end of employment

P60s for prior two years of employment and P45 from last employment
(E) Residing with sufficient resources

Evidence of financial resources and corresponding bank statements (minimum 6 months)

Letter from Department of Social Protection with details of any benefit claims (or stating that there are no claims)

Evidence of Private Medical Insurance (for Sponsor and applicant )

Submission of incomplete forms or failure to submit all requested documentation will result
in the automatic return of your application.

Please return completed forms and documents to:

De Facto Partnerships
Residence Division Unit 5
Irish Naturalisation and Immigration Service
PO Box 12695
Dublin 2

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