CA8454 - HM Revenue & Customs

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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
Declaration Checklist I declare that the information given on this form is correct. I will tell HMRC about any changes in circumstances. Signature Tick the boxes that apply to you. I have filled in this form and signed the declaration. I have enclosed a copy of my latest payslip. Name I am a mariner and I have enclosed a copy of my: • mariners’ discharge book Date DD MM YYYY • completed mariners’ questionnaire. Phone number I am an agent and confirm that my client has sent you a completed form 64-8 Authorising your agent. I know that you cannot deal with me without this authority. CA8454 Page 5
Page 1 and 2: Application for health care cover i
Page 3: 1 Worker’s details continued 17 D

CA8454 - HM Revenue & Customs

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