CA8454 - HM Revenue & Customs

2 Worker living abroad
29
What date did you move to your current country
32
Do you intend to return to the UK?
of residence? DD MM YYYY
Yes
No
If Yes, when do you intend to return? DD MM YYYY
30
In what country were you living before you moved to
your current country of residence?
If No, where do you intend to live in the long term?
31
Give your UK address immediately before leaving the UK
33
Do you maintain a home in the UK?
Yes
No
34
Do you have any dependants living in another EEA
Member State needing health care cover?
Yes go to Part 3
No
go to Declaration
3 Dependant’s details
Please check with the health care institution where you reside to see if an S1 is required for each dependant.
Some EEA Member States cover all dependants on one S1 form. If the health care institution confirms you need an S1
for each dependant then please also provide the name, address, date of birth, nationality and National Insurance number
(if they have one) of each dependant.
35
Full name of dependant
40
Full address
36
Date of birth DD MM YYYY
37
Place of birth
41
Does the dependant carry out any work in their country
of residence?
38
Country of residence
Yes No
If Yes, give details
39
UK National Insurance number
42
Social security number in their country of residence
CA8454 Page 4