Application For Dutch Provisional Residence Permit MVV

Request for Advice
Preceding the Actual Application

for a Regular Provisional
Residence Permit (MVV)
Nederlandse versie
Dit aanvraagformulier is ook verkrijgbaar in het Nederlands. Bel met
0900 1234561 ( 0.10 p.m. plus de kosten voor het bellen met uw
mobiele telefoon). Vanuit het buitenland belt u +31 20 8893045. Of kijk
op: www.ind.nl om dit formulier aan te vragen of te downloaden.
Please read the explanation on this page and the next carefully before you fill in the form.
Why this form?
You can use this form to request advice preceding the actual application
for a Regular Provisional Residence Permit (MVV) on behalf of a foreign
national. Someone who wants to stay in the Netherlands for more than
three months must usually have an MVV or a valid residence permit.
If you would like a foreign national to come and stay with you, you can
request the IND to give advice about whether or not the IND will issue
an MVV to this foreign national. You will then be his/her sponsor (the
person providing him/her residence). For this purpose, the IND needs
information from you as well as from the foreign national. There is no
charge for this advice.
Employers, Please Note! If the foreign national will be performing work
as an employee, as a trainee, or for the purpose of work experience, or as
a guest lecturer, spiritual leader, or teacher of religious knowledge, or in
the capacity of a director-major shareholder or director-shareholder, the
IND recommends that you use the form Request for Advice Preceding
the Actual Application for an MVV for Work as an Employee, which can
be found at www.arbeidsmigratie.nl. If the foreign national will be
employed as a scientific research worker, first visit http://english.ind.nl/
and read the information under Employers.
How to fill in this form
Use one form for each person in respect of whom you are submitting
a request for advice. The form consists of 11 pages and 8 appendices.
Please answer all the questions and follow the instructions. Which
appendices you must fill in and send along, depends on the situation of
the foreign national. This has been indicated in the questions and on
the appendices. If your request for advice is not complete, it cannot be
assessed properly.
Did the foreign national pass the civic integration examination
abroad?
Do not submit this form until the foreign national has passed the civic
integration examination abroad or if you can prove that the foreign
national is exempt from this examination. You can find more
information on page 10 of this form. The civic integration examination
abroad applies to all foreign nationals between 18 and 65 years of age
who are obliged to hold an MVV and who want to come to the
Netherlands for family reunification (except if the foreign national will
be staying with a family member with a permanent or temporary asylum
residence permit), family formation, or as an employee, spiritual leader,
teacher of religious knowledge, or as a foster child (insofar as it concerns
a child of 18 years of age or older). Foreign nationals who want to stay
in the Netherlands as an au pair, as a student, to undergo medical
treatment, or to visit family do not have to take a civic integration
examination abroad. In addition, several categories are exempt from the
civic integration examination abroad. For more information on this see
further under 14 Civic Integration Examination Abroad.
NB. Did you pass the civic integration examination abroad more than
1 year ago? In that case, you must take the examination again if you are
submitting this request for advice. The validity of the civic integration
examination abroad is 1 year.
How to submit this request for advice
Send your request for advice preceding the actual application for an MVV
to the IND. Do not submit this request until you have filled in this form
completely and collected all the required documents, so do not submit it
in parts. Send all the required documents together with your request for
advice. Please use the return envelope accompanying this form. You will
find the relevant address on the enclosed sticker sheet. Use the address
sticker that applies to your situation.
Signature of the sponsor (the person providing residence)

I am requesting the Immigration and Naturalisation Service (IND) to provide me with advice preceding the actual application for
a Regular Provisional Residence Permit (MVV) to be issued to the foreign national mentioned below. I have filled in this form
truthfully. I know that, for the purpose of implementing the Aliens Act 2000, the personal data filled in will be processed and
passed on to the institutions that require these details for that purpose. I will immediately inform the IND of any changes in my
situation or the situation of the foreign national that relate to the residence permit.
Name
|
City/Town
City/Town and date
month
year
Signature
Day
| | I submit this form and

IND5003_M138/11A
Number
of appendices/documents in evidence
2 of 11
What will happen with your request for advice?

Once the IND has received your request for advice, it will send a
confirmation of receipt. The IND will then assess whether the foreign
national will qualify for a stay in the Netherlands for more than three
months. The IND will issue its advice about your request as soon as
possible. You will receive a notice about this. The INDs aim is to provide
you with this advice within three months.
Your employer will apply for a work permit at UWV WERKbedrijf.

It sometimes occurs that your employer has not yet received a decision
on the application for a work permit, whereas you must enclose a copy of
this work permit with the request for advice. In that case, you must send
a copy of the application for a work permit. As soon as the employer has
received the relevant work permit, you must then send a copy of the work
permit to the IND.
What must the foreign national do?

The foreign national must wait in his/her country of origin, or in the
country of permanent residence, until the IND has issued its advice.
A country of permanent residence is a country where the foreign
national is permitted to stay for a period longer than three months on
the basis of a residence permit. If the IND issues a positive advice, the
foreign national must personally submit an application for an MVV at
the Dutch embassy or the Dutch consulate.
Language of the documents to be enclosed

All documents must have been drawn up in Dutch, English, French,
or German. Is this not the case? If this is not the case, you must have
your documents translated by a translator who has been sworn in
as a translator by the Dutch court. Submit the translation(s) and the
document(s) together with the application to the IND. If you do not have
the document(s) translated in the Netherlands by a translator who has
been sworn in as a translator by the Dutch court, but abroad, then not
only the document, but also the translation must have been legalised
or provided with an Apostille stamp by the competent authorities of the
issuing country.
Why is an MVV required?

The foreign national usually requires an MVV to be able to apply for a
Dutch residence permit. The MVV enables the foreign national to enter
the Netherlands, and he/she may then apply for a residence permit for
the same purpose as that for which the MVV has been issued.
In some cases, the foreign national does not require an MVV.
The relevant situations are explained below:
Persons having one of the nationalities of the following countries:
Australia, Austria, Belgium, Bulgaria, Canada, Cyprus, Czech
Republic, Denmark, Estonia, Finland, France, Greece, Germany,
Hungary, Iceland, Ireland, Italy, Japan, Latvia, Liechtenstein,
Lithuania, Luxembourg, Malta, Monaco, New Zealand, Norway,
Poland, Portugal, Romania, Slovenia, Slovakia, Spain, South Korea,
Sweden, United Kingdom, United States of America, and Vatican City.
If the foreign national has worked on a Dutch sea-going vessel or in a
mining installation on the continental shelf for 7 years or more.
If a child was born in the Netherlands and is actually part of your
family. This only applies if the child is 12 years of age or younger, and
you, the parent(s), is/are (a) lawful resident(s) in the Netherlands.
Family members of nationals of the Union who do not have the
nationality of an EU/EEA Member State or Switzerland themselves,
but who do have the right of free movement of persons on the basis
of EU law. These nationals can submit an application for a short-stay
visa to the Dutch representation in the country of origin. In this case,
the relevant EU citizen with whom the foreign national intends to
stay must, however, have used the right of free movement of persons
himself/herself. In principle, a family member of a Dutch national,
although a national of the Union, consequently does not fall under
this regulation and is consequently obliged to hold an MVV.
If an MVV is not required
Even if the foreign national does not require an MVV, it may still be
well-advised to apply for an MVV. In that case, the foreign national is
sure that he will be granted a residence permit before travelling to the
Netherlands. Only in exceptional cases will the holder of an MVV not be
granted a residence permit.
EU/EEA countries
The countries that are members of the European Union (EU) are the
following: Austria, Belgium, Bulgaria, Cyprus, Czech Republic, Denmark,
Estonia, Finland, France, Greece, Germany, Hungary, Ireland, Italy,
Latvia, Lithuania, Luxembourg, Malta, the Netherlands, Poland,
Portugal, Romania, Slovenia, Slovakia, Spain, Sweden, and the United
Kingdom. The countries that are members of the European Economic
Area (EEA) are the following: Liechtenstein, Norway, and Iceland.
Foreign documents
Any official foreign documents about persons that are required for the
application must have been legalised or provided with an Apostille
stamp by the competent authorities of the issuing country. This may
relate to documents such as birth certificates, certificates of unmarried
status (not older than 6 months), marriage certificates, and court
decisions regarding adoption and guardianship. This may take a great
deal of time. We therefore advise you to have the relevant documents
legalised or provided with an Apostille stamp in the country of origin
several months before submitting the request for advice. For more
information about legalisation or Apostille requirements for documents
for each country and any exceptions to this, please call the Ministry of
Foreign Affairs at (+31) (0)70 348 4844 or visit www.minbuza.nl/en/
Services.
Special circumstances
If you think that there are special facts or circumstances that should
be taken into consideration in assessing the request for advice, you
must state these facts and circumstances to the IND in a separate letter.
Enclose this letter with this form. In addition, enclose as many pieces of
evidence as possible to substantiate the contents of your letter.
Dutch Personal Data Protection Act
Under the Dutch Personal Data Protection Act, the IND is obliged to
inform you that the IND is the organisation that processes the data
included in your request for advice. The IND does this to establish
whether you qualify for an asylum residence permit. The Minister for
Immigration and Asylum is responsible for this. If you have any questions
about this data processing, you can ask these questions in a letter to the
IND, Postbus 1200, 2280 GE Rijswijk, the Netherlands. You can also send
a request to the same address asking the IND for an overview of the data
processed about you. With reference to this overview, you may ask the
IND to correct, supplement, delete, or block your personal data.
More information
Please call the IND for more information about this application form or
about your situation. The IND can be reached at 0900 1234561 on
working days from 9 a.m. to 5 p.m. ( 0.10 per minute plus any
additional costs charged by your operator if you are calling from a mobile
telephone), or +31 20 8893045 from outside the Netherlands, or visit
www.ind.nl. You can also go to one of the IND desks. If you want to know
where to find the nearest IND desk, please visit www.ind.nl for this
purpose or call 0900 1234561 ( 0.10 per minute plus any additional
costs charged by your operator if you are calling from a mobile phone).
Work permit (twv)

If you want to work as an employee, you will often need a work permit
(twv). For more information, please contact UWV WERKbedrijf (which
is the work placement division of the Netherlands Employees Insurance
Agency) at www.werk.nl.
IND5003_M138/11A
Request for Advice

1
3 of 11
Preceding the Actual Application for a Regular Provisional Residence Permit
(MVV)
Immigration and Naturalisation Service
Ministry of the Interior and Kingdom Relations
Details of the sponsor (the person providing residence)

Complete all of the details of the sponsor requested below. You are the foreign nationals sponsor. The sponsor is the person
with whom the foreign national will be residing, or the organisation that is funding his or her stay in the Netherlands. If you are
submitting a request for advice on behalf of an organisation, you are the contact person for this organisation.
1.1 Citizen Service Number

(BSN) (if known)
Surname as it appears in your passport or on your identity papers
1.2 Name
| |
1.3 Gender
n Male n Female
First names
Street
1.4 Home address
Number
|
Postal code

Day
month
City/Town
year
1.5 Date of birth

1.6 Place of birth
1.7 Country of birth
1.8 Nationality
1.9 Civil status
1.10 Telephone number

1.11 E-mail
1.12 Residence status
n Dutch nationality
n Awaiting the outcome of an application for a residence permit
n None
n Residence permit
> Fill in only in cases of
n Privileged
work/study
1.13 Name of the organisation |

1.14 Contact person
Details of the foreign national (abroad)

First names
2.1 Name
| |
2.2 Gender
n Male n Female
Street
2.3 Home address
|
Postal code

Day
month
City/Town
| |
year
2.4 Date of birth

2.5 Place of birth
2.7 Nationality
Country
IND5003_M138/11A
Number
4 of 11
2.9 E-mail
City/Town
2.10 Embassy or consulate

where the foreign national will submit the MVV
Country
| |
Purpose of stay in the Netherlands
Please state the main purpose of stay in respect of which you are submitting a request for advice for the foreign national.
Tick the most important purpose of stay and follow the instruction there. You may not tick more than one purpose of stay in this
form. If you tick more than one purpose of stay, your request for advice will only be assessed on the purpose ticked first.
n To stay with a relative or family member
If the foreign national wants to stay with a relative or family member who is
already living in the Netherlands. This also applies for holders of temporary
asylum residence permits who want their spouse, partner or registered partner,
or children to travel to the receiving country to join them within 3 months.
> Go to 4 on page 4 and follow the instruction written below this purpose of stay.
n To work as an employee
If the foreign national wants to work as an employee for a Netherlands-based
company.
Employers, Please Note! If the foreign national will be performing work as an
employee, as a trainee, or for the purpose of work experience, or as a guest
lecturer, paid or unpaid research worker, spiritual leader, or teacher of religious
knowledge, or in the capacity of director-major shareholder or directorshareholder, the IND recommends that you use the form Request for Advice
Preceding the Actual Application for an MVV for Work as an Employee for your
request for advice. You can order this form or download it from INDs website
at www.ind.nl. You can also fill it in by using the form module on this website.
You can also order this form by sending an e-mail to the Knowledge and Labour
Migration Desk of the IND: arbeid@ind.minbzk.nl.
n To work as a border-crossing services provider
If a foreign national (the service provider) does not have an EU/EEA nationality,
but lives in an EU/EEA country and is a lawful resident in that country and he/she
will be providing services on the instruction of his/her employer (the services
company) on a temporary basis.
n To work on a self-employed basis
If the foreign national wants to practise a profession or operate a business in
the Netherlands on a self-employed basis.
n For study purposes

If the foreign national wants to attend a Secondary Education course or a
Vocational Education course.
n For exchange purposes
If the foreign national wants to become acquainted with Dutch society and
culture through the Working Holiday Scheme, the Working Holiday Program,
or through a private organisation.
n As an au pair
If the foreign national wants to stay in a host family as an au pair, in order to
become acquainted with Dutch society and culture in this way.
n On religious or ideological grounds
If the foreign national wants to stay in the Netherlands with a religious or
ideological organisation.
n To undergo medical treatment
If the foreign national wants to stay in the Netherlands to undergo medical
treatment here.
n Otherwise, due to special and individual circumstances
State in a separate letter for which purpose the foreign national wants to apply
for a provisional residence permit. Enclose this letter together with as many
pieces of evidence and documents of the special circumstances as possible with
this request for advice. If the IND has any further questions, you will receive a
letter after having submitted this form.
> Go to 15 on page 11
n To work on the basis of an international treaty

If the foreign national wants to work for a Netherlands-based company or
wants to practise a profession or operate a business on a self-employed basis in
the Netherlands on the basis of an international treaty.
Provisional Residence Permit for Stay with a relative or a family member
Please state the specific reason why you are submitting a request for advice regarding the foreign national. Tick the most important
purpose of stay and follow the instruction there. You may not tick more than one purpose of stay in this form. If you tick more than
one purpose of stay, your request for advice will only be assessed on the purpose ticked first.
n T
he foreign national is married to you or has a registered partnership
with you, and you live in the Netherlands
Your request for advice must be accompanied by the following supplementary
evidence and documents:
Proof of your income, see Appendix Proof of Income;
An original extract (not a copy) from the Municipal Administration (GBA)
showing your home address and the composition of your family. This extract
may not be older than 6 months;
Copies of all the pages containing the identification details of your Dutch
passport or identity card. Also make copies of the pages containing travel
stamps. If you do not have Dutch nationality, please make copies of the
front and back of the Dutch residence permit or of the pages containing the
identification details of the valid border-crossing document (e.g. a passport)
in which the residence permit has been recorded. Also make copies of the
pages containing travel stamps and the residence permit. It is not necessary
to copy empty pages.
If it concerns a marriage, you must also submit the following:

A copy of the registration of the marriage in the Municipal Administration (GBA);
A copy of the marriage certificate (see the explanation on Foreign
Documents and Language on page 2 of this form).
If it concerns a registered partnership, you must also enclose the following:
A copy of the registration of the registered partnership in the Municipal
Administration (GBA);
A copy of the certificate of registered partnership.
n T
he foreign national is your unmarried partner, and you live in the
Netherlands
IND5003_M138/11A
Request for Advice

The Appendix Sponsor Declaration filled in completely and signed by you;
A copy of the declaration of unmarried status relating to you. The declaration
of unmarried status must originate from your country of origin, unless you
have Dutch nationality or a permanent residence permit (see the explanation
Foreign Documents and Language on page 2 of this form)
A copy of the declaration of unmarried status relating to the foreign national,
originating from the foreign nationals country of origin or from the country
where the foreign national is permitted to stay on the basis of a residence
permit for a period of longer than 3 months ). See the explanation on
Foreign Documents and Language on page 2 of this form;
n T
he foreign national is a minor child (younger than 18 years of age) of
you and your spouse or partner or registered partner, and you live in the
Netherlands
Proof of your income and/or the income of your spouse or partner or
registered partner, see Appendix Proof of Income;
Copies of all the pages containing the identity details of the Dutch passport(s)
or identity card(s) of you and your spouse or partner or registered partner.
Also make copies of the pages containing travel stamps. If you or your
spouse or partner or registered partner does not have Dutch nationality,
please make copies of the front and back of the Dutch residence permit or of
the pages containing the identification details of the valid border-crossing
document (e.g. a passport) in which the residence permit has been recorded.
Also make copies of the pages containing travel stamps and the residence
permit. It is not necessary to copy empty pages.
A copy of the foreign nationals birth certificate;
Documents relating to the parental authority you have over the foreign
national (if the child was born during your marriage, a birth certificate will
suffice).
If it concerns a child by a previous relationship of you or your spouse or partner or registered
partner, also submit the following:
A signed declaration of consent by the parent staying behind in respect of
the childs departure from the country of origin (if the parents have joint
custody);
Copies of all pages of the identification document of the parent staying
behind;
n Y
ou have a temporary asylum residence permit and you want your
spouse, partner or registered partner, or child to travel to the receiving
country to join you within 3 months after you have been granted an
asylum residence permit
Documents showing the family relationship with the foreign national;
- In the case of a spouse: a copy of the marriage certificate;
- In the case of a partner or registered partner: documents showing the
cohabitation or the joint partnership in the country of origin;
- If it concerns a child: a copy of the birth certificate.
NB. These foreign documents do not have to be legalised. If you cannot
send along the foreign documents, you must explain in a separate letter why
you cannot send these documents along.
5 of 11
(MVV)
n T
he foreign national is a family member of yours, but not your adult
child, marriage partner, registered partner or partner, and you live in the
Netherlands
Copies of all the pages containing the identity details of the Dutch
passport(s) or identity card(s) of you and your spouse or partner or
registered partner. Also make copies of the pages containing travel stamps.
If you or your spouse or partner or registered partner does not have Dutch
nationality, please make copies of the front and back of the Dutch residence
permit or of the pages containing the identification details of the valid
border-crossing document (e.g. a passport) in which the residence permit
has been recorded. Also make copies of the pages containing travel stamps
and the residence permit. It is not necessary to copy empty pages.
The Appendix Sponsor Declaration filled in completely and signed by you
(and, if applicable, your spouse or partner or registered partner);
A copy of the declaration of unmarried status relating to the foreign
national. This declaration of unmarried status must originate from the
country of origin of the foreign national, or from the country where the
foreign national is permitted to stay for a period of longer than 3 months on
the basis of a residence permit (see the explanation on Foreign Documents
and Language on page 2 of this form);
Documents showing the family relationship between you and the foreign
national (e.g. a copy of a marriage booklet, a birth certificate, or a family
extract from the register of births, deaths, marriages and registered
partnerships) (see the explanation on Foreign Documents and Language
on page 2 of this form);
Documents relating to the family life you had with the foreign national in
the country of origin before you took up residence in the Netherlands;
Documents relating to the family life you had with the foreign national in
the country of origin after you took up residence in the Netherlands;
Documents relating to the family with whom the foreign national is staying
or can stay in the country of origin;
Evidence that leaving the foreign national behind in the country of origin
would be disproportionately harsh (e.g. documents showing that there are
no relatives left in the country of origin, that the foreign national depends on
you or your spouse or partner or registered partner and/or that the foreign
national is not capable of coping independently in the country of origin);
Evidence relating to the contributions towards the costs of the foreign
nationals upbringing, education and living expenses since you took up
residence in the Netherlands (e.g. deposit receipts or bank statements).
If the foreign national is an adult child of you, also submit the following:
Documents showing that you actually had custody over the foreign national
(e.g. evidence showing that you or your spouse or partner or registered
partner are/ were involved in important decisions concerning the
upbringing, education and/or care of the foreign national, including
decisions regarding choice of school, housing, and social development).
n T
he foreign national wants to visit you as a family member (for a period
of longer than 3 months and not more than 6 months)
Proof of income of your relative, see Appendix Proof of Income;
A copy of the family members return ticket or other evidence showing that
the family member has sufficient means for the journey back;
Documents showing the family relation between you and the foreign
national (a copy of, for example, a marriage booklet, birth certificate, or
a family extract from the register of birth, deaths and marriages); See the
explanation on Foreign Documents and Language on page 2 of this form;
IND5003_M138/11A
6 of 11
If the foreign national does not have sufficient means of existence, also submit the
following:
or another relative of the foreign national in the Netherlands.
n T
he foreign national is a family member of yours, and you are a minor
foreign national and holder of a temporary asylum residence permit
A copy of the front and back of your residence permit;
Evidence showing that the foreign national is a blood relative in the
ascending line (father, mother, grandfather, grandmother).
If the foreign national has a different nationality from you, also submit the following:
Evidence that you have not been admitted/will not be granted admission to
the country of that other nationality.
If you submit this advice more than 3 months later than the date on which you were granted
the asylum residence permit, also submit the following:
If you have meanwhile reached the age of 18 years, also submit the following:
Evidence that the Dutch Court has appointed a guardian or mentor because
of your mental faculties.
n T
he foreign national is a family member of yours, and you are staying in
the Netherlands as non-privileged NATO personnel
Documents showing the family relationship with the foreign national (see
the explanation on Foreign Documents and Language on page 2 of this
form):
- In the case of a spouse: a copy of the marriage certificate;
- In the case of a child: a copy of the birth certificate;
- In the case of a relation by blood or affinity (also children of 21 years of
age or older): a document showing the family relationship and evidence
showing that the foreign national will depend financially on your or your
spouse or partner or registered partner.
n The foreign national is your father or mother and is 65 years of age or
older and single, and you live in the Netherlands
You have Dutch nationality and either a Dutch permanent residence permit
(regular or on the basis of asylum) or a temporary asylum residence permit.
registered partner and/or the income of other children of the foreign
national staying in the Netherlands if these children are also sponsors, see
Appendix Proof of Income;
Copies of all pages of the identification documents of other children of the
foreign national who have the Dutch nationality and live in the Netherlands,
or of the front and back of the residence permits or of all pages of the
passports containing the identification details, stamps, travel stamps, and
endorsements of your valid border-crossing document in which the
residence permits have been recorded of the other children of the foreign
national who live in the Netherlands. It is not necessary to copy empty
pages.
(and, if applicable, your partner). If other children of the foreign national
who live in the Netherlands are sponsors, they (and, if applicable, their
spouse or partner or registered partner) must also completely fill in and sign
the Appendix Sponsor Declaration;
a family extract from the register of birth, deaths and marriages). See the
The divorce certificate of the foreign national or the death certificate of the
spouse or partner or registered partner of the foreign national or an extract
from the register of death, births, and marriages from the country of origin
showing that the foreign national is single (see the explanation on Foreign
Documents and Language on page 2 of this form);
Documents showing the family composition of the foreign national (number
of children) (see the explanation on Foreign Documents and Language on
page 2 of this form);
showing your home address and the composition of the family of the other
children of the foreign national who live in the Netherlands. This extract may
not be older than 6 months;
n Y
ou are the father or mother of a minor child that lives in the Netherlands
and you want to have a family life with this child on the basis of Article 8
of the ECHR.
NB. You cannot submit this request for advice if you cohabit with a spouse or
partner or registered partner or you intend to cohabit with this spouse or
partner or registered partner in respect of whom you could submit an
application to stay with him/her. If you do not comply with this condition and
you are submitting this request for advice nevertheless, your request will be
tested against the condition for residence with a spouse or partner or registered
partner. You must accompany the request for advice by the following:
Copies of all pages containing identification details, stamps, travel stamps
and endorsements of the identification document of your minor child if he
or she is a Dutch national, or of the front and back of the residence permit
or of all pages of containing the identification details, stamps, travel stamps,
and endorsements of the valid border-crossing document in which the
residence permit of the minor child has been recorded. It is not necessary to
copy empty pages.
Evidence showing the family relationship between you and the minor child
(e.g. a copy of a birth certificate). See the explanation on Foreign
Documents and Language on page 2 of this form;
Evidence showing the manner in which you give content to the family life
with your minor child.
n T
he foreign national is a foster child of a family member, and you live in
the Netherlands
NB. This request must concern a foster child of a family member. The person
providing residence may only be the foster childs grandparent, brother, sister,
uncle, or aunt.
passport(s) or identity card(s) of you and, if applicable, your spouse or
partner or registered partner. Also make copies of the pages containing
travel stamps. If you or spouse or partner or registered partner do not have
Dutch nationality, please make copies of the front and back of the Dutch
residence permit or of the pages containing the identification details of the
valid border-crossing document (e.g. a passport) in which the residence
permit has been recorded. Also make copies of the pages containing travel
stamps and the residence permit. It is not necessary to copy empty pages.
A copy of the medical certificate of the foreign nationals state of health;
Evidence showing that the parents or legal representatives consent to the
foreign national coming to live with you in the Netherlands. Insofar as
required by the law of the country of origin, you must also submit evidence
showing that the authorities in the country of origin consent to the foreign
national taking up residence with the family of the person providing
residence (see the explanation on Foreign Documents and Language on
page 2 of this form);
a family extract from the register of birth, deaths and marriages). See the
A written statement of reasons of the special circumstances of the foreign
national or the special circumstances of the family members in the country
of origin showing that the foreign national cannot be taken care of, at least
not properly, by family members or relatives who live in the country of
origin;
A certificate (e.g. a guardianship certificate) issued by the competent
authorities certifying that the authority over the foster child rests with the
foster parents.
IND5003_M138/11A
Request for Advice

n T
he foreign national has not yet been adopted, but will be adopted in
your family
or identity card(s) of you and, if applicable, your spouse or partner or
A copy of the Approval in Principle of the Ministry of Security and Justice,
Directorate-General for Prevention, Youth and Sanctions;
A copy of the declaration showing that a licensed adoption placement
agency was used. If no use has been made of such licensed adoption
placement agency, a Declaration of Approval of the Ministry of Security and
Justice, Directorate-General for Prevention, Youth and Sanctions.
A copy of the medical certificate of the foreign nationals state of health, as
referred to in the Dutch Placement of Foreign Foster Children Act, issued in
the country of origin. This certificate may not be older than 6 months (see
form);
A copy of the official decision of the authority competent in the matter in
the country of origin (e.g. the official judgment of the court in the country of
origin) as well as a translation of this decision. This must show that you are
permitted to adopt the child into your family and that the authorities of the
country of origin consent to the foreign national being adopted into your
family (see the explanation on Foreign Documents and Language on page
2 of this form);
Documents showing that the parent(s) has/have relinquished the foreign
national (this approval may be evident from the above-mentioned
judgment) (see the explanation on Foreign Documents and Language on
page 2 of this form).
7 of 11
(MVV)
n T
he foreign national has been adopted by you immediately following an
adoption judgment, and you live in the Netherlands
or identity card(s) of you and, if applicable, your spouse or partner or
A copy of the Approval in Principle of the Ministry of Security and Justice,
Directorate-General for Prevention, Youth and Sanctions;
A copy of the declaration showing that a licensed adoption placement agency
was used. If no use has been made of such licensed adoption placement
agency, a Declaration of Approval of the Ministry of Security and Justice,
Directorate-General for Prevention, Youth and Sanctions.
A copy of the medical certificate of the foreign nationals state of health, as
referred to in the Dutch Placement of Foreign Foster Children Act, issued in
the country of origin. This certificate may not be older than 6 months (see
form);
A copy of the official decision of the authority competent in the matter in
the country of origin (e.g. the official judgment of the court in the country
of origin) as well as a translation of this decision. This must show that you
are permitted to adopt the child in your family and that the authorities of
the country of origin consent to the foreign national being adopted in your
family (see the explanation on Foreign Documents and Language on page
2 of this form);
Documents showing that the parent(s) has/have relinquished the foreign
national (this approval may be evident from the above-mentioned
judgment) (see the explanation on Foreign Documents and Language on
page 2 of this form).
If it concerns an adoption decision made by a foreign authority that has applied the Hague
Adoption Treaty, also submit the following:
A conformity statement
Regular Provisional Residence Permit to work as an employee
If you want to submit a request for advice regarding work as an employee, do not use this form but visit www.arbeidsmigratie.nl.
You can use this form for special purposes of stay whereby the foreign national wants to perform work in the Netherlands.
Please state the specific reason why you are submitting a request for advice for the foreign national. Tick the most important
n As non-privileged NATO personnel
Proof of the foreign nationals income, see Appendix Proof of Income;
n The foreign national wishes to spend his/her leave in the Netherlands
during work in a mining installation on the continental shelf
Evidence showing that the foreign national will work for at least one year
as an employee in a mining installation on the continental shelf, by which
sufficient means of existence will be acquired in a sustainable manner, see
Appendix Proof of Income.
n After having worked on a Dutch sea-going vessel or in a mining
installation on the continental shelf for 7 years or more
A letter stating the reasons why the foreign national wants to come to the
Netherlands (for work on Dutch territory, or to spend a leave period in the
Netherlands, or due to illness, or due to unemployment);
Evidence of the foreign nationals employment history on board a Dutch

sea-going vessel or in a mining installation on the continental shelf (e.g. a
copy of the foreign nationals seamans book or employment agreement).
In the case where this employment history has been interrupted:
-D
ocuments relating to the duration and reason of this interruption; and (if
applicable)
- Documents relating to the benefits received by the foreign national;
Proof of the national insurance schemes originating from the foreign
nationals employment in respect of a social security treaty concluded by the
Netherlands or in respect of the Dutch national insurance schemes;
An overview of the periods in which the foreign national was unemployed or
when the foreign national did not work on board a sea-going vessel or in a
mining installation on the continental shelf.
If the foreign national wants to spend his/her leave in the Netherlands, also submit the
following:
Evidence showing that the foreign national spent his/her leave periods
nearly entirely in the Netherlands during the employment history;
Evidence showing that the foreign national will work for at least one year as
an employee on board a Dutch sea-going vessel or in a mining installation on
the continental shelf, by which sufficient means of existence will be acquired
in a sustainable manner.
IND5003_M138/11A
8 of 11
Regular Provisional Residence Permit to work as a border-crossing service provider
n To work as a border-crossing service provider

A copy of the residence permit and, if required, a copy of the work permit
showing that the foreign national is entitled to stay in the country where the
services company has its registered office and to work there as an employee
of the services company (if you have this work permit);
A copy of the employment agreement with the employer (the services
company).
Regular Provisional Residence Permit to work on a self-employed basis
n To work on a self-employed basis

evidence and documents, in duplicate and not bound:
If required: a copy of a document issued by the Dutch authority competent
in this matter showing that the foreign national is qualified to practise a
profession or operate a business;
A copy of the business plan, including the following information:
- Information of the foreign national (personal data, family and income
situation, financial obligations, education, and professional experience);
- Business information (information about the line of industry in which the
foreign national will work, starting date of the enterprise, and place of
business);
- Legal aspects (legal form of the enterprise, trade name, licences, liability,
insurance, and supply conditions);
- Commercial aspects (market potential):
a) A description of the type of business and product (features, application,
need, innovative character, and unique selling points);
b) A market analysis (description and size of the market, and potential
customers/market share), competitors, barriers, co-operations, and risks;
c) price breakdown, substantiated by agreements and references.
- Management aspects (description of the organisational structure of the
enterprise, the required competencies, and the number of staff);
- Financial aspects (investment budget, financing plan, repayment schedule,
opening balance sheet, balance sheet, operating budget, and liquidity
forecast);
NB. The financial documents must have been prepared or assessed by an
independent expert. If any new jobs are created, this must be demonstrated
by either the contents of the business plan, which must, in particular, show
the feasibility of the financial aspects, or by employment agreements.
A copy of the deed of incorporation showing the powers, responsibilities,
and allocation of the profit among the partners (if it concerns a general
partnership or a limited partnership);
A certificate of registration at the Chamber of Commerce;
In the case of freelance activities on a self-employed basis: Agreement(s)
for the provision of services showing that the foreign national will perform
activities on a freelance basis.
It is your responsibility to substantiate your request for advice as much as
possible by evidence showing that the foreign nationals enterprise can make
a major contribution to the Dutch economy. For this purpose, you must also
submit the following documents in duplicate and not bound:
Copies of diplomas obtained (if the diploma(s) were obtained abroad; the
diploma(s) must have been recognised by the Nuffic);
Copies of certificates of education courses in the Netherlands or abroad
(diploma(s) or Doctorates);
Evidence of any previous experience gained as an entrepreneur if there is
also an enterprise in the country of origin, you must also submit a deed of
incorporation and the articles of association of this enterprise;
Evidence of previous work experience, for example by submitting
reference(s), testimonial(s), and/or employment agreement(s) from/with
former employer(s);
Income statement over the last 12 months before the application, for
example by submitting an annual income statement, tax assessment, or
employment agreement(s);
Evidence of experience in the Netherlands, for example by means of
agreement(s) or reference(s) of Dutch partners and business partners, or
sales figures concerning the Dutch market.
NB. If you have failed to substantiate your request for advice sufficiently by
means of the above-mentioned documents, your request will not be submitted
for advice to the Minister of Economic Affairs, Agriculture and Innovation.
n W
ork on a self-employed basis, and the foreign national has Turkish
nationality
evidence and documents, in duplicate and not bound:
If required: a copy of a document issued by the Dutch authority competent
in this matter showing that the foreign national is qualified to practise a
profession or operate a business;
A copy of the business plan, including the following information:
- I nformation about the foreign national (personal data, family and income
situation, financial obligations);
-B
usiness information (information about the line of industry in which the
foreign national will work, starting date of the enterprise, and place of
business);
- L egal aspects (legal form of the enterprise, trade name, licences, liability,
insurance, and supply conditions);
-C
ommercial aspects (market potential):
a) description of the type of business and product (features, application,
need, and unique selling points);
b) A market analysis (description and size of the market, and potential
customers/market share), competitors, barriers, co-operations, and risks;
c) price breakdown, substantiated by agreements and references.
NB. The financial documents must have been prepared or assessed by an
independent expert.
A copy of the deed of incorporation showing the powers, responsibilities,
and allocation of the profit among the partners (if it concerns a general
partnership or a limited partnership);
A certificate of registration at the Chamber of Commerce;
In the case of freelance activities on a self-employed basis: Agreement(s)
for the provision of services showing that the foreign national will perform
activities on a freelance basis.
It is your responsibility to substantiate your request for advice as much as
possible by evidence showing that the foreign nationals enterprise can make a
major contribution to the Dutch economy.
NB. If you have failed to substantiate your request for advice sufficiently by
means of the above-mentioned documents, your request will not be submitted
for advice to the Minister of Economic Affairs, Agriculture and Innovation.
Regular Provisional Residence Permit to work on the basis of an international treaty
n T
o perform activities as an employee in the context of an EU action
programme or an international agreement to which the Netherlands is a
party
evidence:
Evidence showing that paid research or paid work will be carried out by
the foreign national in the context of an EU action programme or an
international agreement to which the Netherlands is a party, or proof of the
foreign nationals income, see Appendix Proof of Income;
IND5003_M138/11A
Request for Advice
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(MVV)
9 Regular Provisional Residence Permit to attend a Secondary Education Course or

a Vocational Education course
If you want to attend an institution of higher education or a university, do not use this form, but contact the educational institution.
n To attend a Secondary Education Course or a Vocational Education course
Evidence showing the foreign nationals registration (provisional or definite)
at, or admission to, the institution. This evidence must have been issued by
the competent authority of the educational institution;
Only if the foreign national is awarded a study grant: a copy of the document
awarding the study grant;
A written explanation of the reason why the Netherlands is the most
suitable country to attend this course and in which sense the course
contributes positively to the labour market in the country of origin;
In the case of an Upper Secondary Vocational Education course (MBO), a
declaration from the COLO that this education course cannot be attended in
the country of origin (see COLOs website for more information www.colo.nl);
In the case of a Secondary Education course, a declaration of the Ministry of
Education in the country of origin stating that the relevant course cannot be
attended in the country of origin.
If the foreign national or a third party abroad (e.g. a private person or a legal person) will
wholly or partially pay for the course, also submit the following:
A copy of the bank statement from a bank account jointly or exclusively
made out in the name of the foreign national with the balance that is
available to the foreign national for the study year; or
10
An original declaration from the bank (not a copy) showing which amount
is transferred in favour of the foreign national to a bank account jointly or
exclusively made out in the name of the foreign national.
If you (the financial sponsor) will pay for the study, also submit the following:
and, if applicable, your spouse or partner or registered partner;
passport(s) or identity card(s) of you and, if applicable, your spouse or
partner or registered partner. Also make copies of the pages containing
travel stamps. If you or your spouse or partner or registered partner does
not have Dutch nationality, please make copies of the front and back of the
Dutch residence permit or of the pages containing the identification details
of the valid border-crossing document (e.g. a passport) in which the
residence permit has been recorded. Also make copies of the pages
containing travel stamps and the residence permit. It is not necessary to
copy empty pages.
Regular Provisional Residence Permit for Exchange Purposes
Please state the specific reason why you are submitting a request for advice for the foreign national. Tick the most important
n Exchange through a private organisation
showing the home address and composition of the host family. This extract
If it concerns voluntary work, also submit the following:
A copy of the work permit issued by the UWV WERKbedrijf (see the
explanation on 'work permit' on page 2 of this form).
11
n Exchange on the basis of the Working Holiday Scheme or Working

Holiday Program
A copy of the return ticket or evidence showing that the foreign national has
sufficient means to buy a return ticket.
Regular Provisional Residence Permit as an Au Pair
n as an au pair
NB. At the time of submitting the application for the residence permit in the
Netherlands, the au pair must at least be 18 years of age, but not yet 26 years
of age.
A description of the foreign nationals timetable (nature and duration of the
activities);
A description about the manner in which the foreign national will become
acquainted with Dutch society and culture.
IND5003_M138/11A
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12 Regular Provisional Residence Permit to Stay in the Netherlands with a Religious or

Ideological Organisation
n On religious or ideological grounds
The monastery or convent or religious or ideological organisation must submit
the following supplementary evidence and documents when this request for
advice is submitted:
A written explanation about the need for the foreign national to stay with
the religious or ideological organisation;
Written evidence showing that the foreign national at the time of the
application was already a member of the religious or ideological organisation;
A detailed description of the activities that the foreign national will perform
at or through the intermediary of the religious or ideological organisation;
A written statement of the means by which the stay of the foreign national
will be paid (which facilities will the foreign national receive at the expense
of the organisation);
The Sponsor and Awareness Declaration concerning the stay with religious
or ideological organisations filled in completely and signed by the
organisation;
The Appendix Awareness Declaration Regarding the Transitional Regime
on Religious or Ideological Grounds filled in completely and signed by the
organisation;
Written evidence by which the organisation or the monastery or convent
shows that it has sufficient financial means and that it is capable of providing
for the foreign nationals living expenses.
13
Regular Provisional Residence Permit to Undergo Medical Treatment
n To undergo medical treatment

The Appendix Medical Information Disclosure Consent Form filled in
completely and signed by the foreign national. If several doctors are in charge
of the foreign nationals treatment, the consent to contact these doctors
must be given separately for each doctor. This consent must be given with
respect to the doctor(s) in charge of the treatment in the Netherlands as well
as the doctor(s) in charge of the treatment in the country of origin;
Proof of insurance for medical expenses incurred in the Netherlands or any
other evidence showing that the financing of the costs of the medical
treatment has been arranged.
A written explanation of why the Netherlands is the most appropriate
country to undergo the relevant medical treatment(s). Accompany the
request for advice with as many pieces of evidence as possible.
Evidence showing that the foreign national has sufficient means of existence
to pay for his/her living expenses for the duration of his/her stay in the
Netherlands;
14
If the foreign national intends to stay with another organisation than the
following:
The Stichting Jeugd met een Opdracht, in Heerde; or
Kerk van Jezus Christus van de Heiligen der Laatste Dagen, in Dordrecht; or
Centraal Missie Commissariaat, in The Hague; or
The Syrian Orthodox Church, in Losser; or
Stichting Congregatie FIC, in Maastricht; or
Maharishi European Research University/Maharishi Vedic University, in
Vlodrop; or
Stichting International Buddhist Progress Society Holland, in Amsterdam; or
An individual monastery or convent,
the religious or ideological organisation must then also submit the following:
Evidence showing that in the five years preceding the effective date of this
scheme (8 January 2004) a residence permit was granted to a foreign
national on religious or ideological grounds in respect of the organisation
where the foreign national intends to stay. In this context, the reason for
applying for a residence permit is not for study purposes or to work as an
employee.
If the foreign national does not have sufficient means of existence, also submit the following:
The Appendix Sponsor Declaration filled in completely and signed by a
family member or other relation of the foreign national in the Netherlands.
Proof of the guarantors income and, if applicable, the income of his/her
spouse or partner or registered partner, see Appendix Proof of Income;
Copies of all the pages containing the identification details of the
guarantors Dutch passport or identity card. Also make copies of the pages
containing travel stamps. If the guarantor does not have Dutch nationality,
please make copies of the front and back of the Dutch residence permit or of
the pages containing the identification details of the valid border-crossing
document (e.g. a passport) in which the residence permit has been recorded.
Also make copies of the pages containing travel stamps and the residence
permit. It is not necessary to copy empty pages.
Civic Integration Examination Abroad
The foreign national must take the civic integration examination abroad when he/she is at least 18 years of age, but not yet 65 years
of age. In some cases the foreign national is exempt from the examination on the basis of diplomas, certificates, or other documents.
Tick the situation that applies to the foreign national and enclose any documents required to the request for advice.
NB. Did the foreign national pass the civic integration examination abroad more than 1 year ago? In that case, the foreign national
must take the examination again if you want to submit your request for advice. The validity of the civic integration examination
abroad is 1 year.
n T
he foreign national does not have to take a civic integration examination abroad, because he/she wants to come to the Netherlands to stay
as a family member with a holder of a temporary or permanent asylum
residence permit; or because he/she is permitted to stay with a national
of the Union; or because he/she will be staying in the Netherlands to
visit a family member, for adoption, to work as an employee (except for
the purpose of working as a religious leader or as a teacher of religious
knowledge), to work on a self-employed basis, or on the basis of an
international treaty or an exchange programme, to study, or as an au pair;
or to undergo medical treatment. This also applies to family members of
the foreign national with one of the above-mentioned purposes of stay.
n T
he foreign national has the Surinamese nationality and has been taught
in the Dutch language at least at primary school level
If at least primary school was finished in Surinam before 25 November 1975, also submit
the following:
A diploma or certificate of at least primary school and a declaration of the
Surinam Central Bureau for Population Affairs (Centraal Bureau Burgerzaken)
provided with an Apostille stamp showing that the foreign national lived
in Surinam at the time when he/she finished primary school or secondary
school (see the explanation on Foreign Documents and Language on page
2 of this form);
If at least primary school was finished in Surinam after 25 November 1975, also submit the
following:
A school diploma or certificate issued by the Surinamese Ministry of
Education and Adult Education obtained in Surinam showing that the
foreign national finished at least primary school or a course conducted in
Dutch or a declaration of the Examination Agency of the Ministry of
Education and Adult Education showing the same. The diploma, certificate,
or the declaration must be provided with an Apostille stamp (see the
explanation on Foreign Documents and Language on page 2 of this form);
If the foreign national attended primary school in the Netherlands, also submit the following:
An extract (with the historical address details) from the Municipal
Administration (GBA) or a legalised historical overview issued by the
Settlement Register (Vestigingsregister) (in The Hague) showing that the
foreign national lived in the Netherlands at the age of 11, 12 or 13 years.
If the foreign national attended a higher education course in the Netherlands, also submit
the following:
A copy of the Dutch education diploma.
IND5003_M138/11A
Request for Advice

n T
he foreign national is not able to take a civic integration examination
abroad, on medical grounds
This may, for example, be due to a serious physical or mental impairment, such
as blindness, deafness or deaf-muteness. In that case, the foreign national must
undergo a medical examination. This medical examination will be performed by
a physician designated by the Dutch representation in the country of origin.
The foreign national must, however, give the physician permission to forward
the completed medical questionnaire.
evidence:
A copy of the medical questionnaire filled in completely and signed by a
doctor designated by the Dutch representation in the country of origin.
n T
he foreign national has one of the following diplomas, certificates or
documents which entitle him/her to claim exemption from the civic
integration examination abroad
NB. If the diploma has not been issued in the Netherlands, the diploma or
certificate must be provided with an Apostille. In some cases, you will also have
to send along a list of marks. This is only required if you were required to have
passed the Dutch language course.
Your request for advice must be accompanied by one of the following
supplementary evidence and documents:
The Civic Integration Certificate under the Civic Integration Act;
A diploma of, for example, a university, Higher Professional Education
(HBO), Upper Secondary Vocational Education (MBO), Pre-University
Education (VWO), Senior General Secondary Education (HAVO), Junior
General Secondary Education (MAVO), or Pre-Vocational Secondary
Education (VMBO). The foreign national has such a diploma if the diploma
states, for example: Wet op het hoger wetenschappelijk onderwijs, Wet op
het voortgezet onderwijs, Wet educatie beroepsonderwijs, or Wet op het
cursorisch onderwijs.
State Examination in Dutch as a Second Language, (programme I or II);
A school diploma obtained in Belgium or Surinam. The education must have
been conducted in Dutch. In addition, the foreign national must have
passed the Dutch language course. The educational level must be higher
than primary school and the diploma must be based on an Act. This Act need
not necessarily be an Education Act;
A diploma, certificate or other document obtained in education conducted
in Dutch in the Netherlands Antilles or Aruba, provided that the foreign
national passed the Dutch language course. This concerns the following
diplomas: Junior General Secondary Education (MAVO), Senior General
Secondary Education (HAVO), Pre-University Education (VWO), Lower
Secondary Vocational Education (LBO), Upper Secondary Vocational
Education (MBO), Higher Professional Education (HBO), and University;
15
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(MVV)
The European Baccalaureate awarded by one of the European Schools.
The foreign national must have taken Dutch as a first or second language.
In addition, the foreign national must have passed the Dutch language course;
International Baccalaureate Middle Years Certificate or an International
General Certificate of Secondary Education or an International Baccalaureate.
In addition, the foreign national must have passed the Dutch language course;
The Naturalisation Certificate;
A Civic Integration Certificate (Certificaat Inburgering) under the Dutch Civic
Integration (Newcomers) Act. This must be accompanied by a declaration
of the regional training centre (ROC). This declaration must state that the
foreign national passed all components of Dutch as a Second Language at
least at level 2. The declaration must also state that the foreign national also
passed Social Orientation at level 2;
Settled Immigrants Civic Integration Certificate (Certificaat Inburgering
Oudkomers) with:
- level NT2 2 for the components Listening and Speaking; and
- level NT2 1 for the components Reading and Writing;
The exemption test (Korte Vrijstellingstoets) under the Dutch Civic
Integration Act;
A letter from the Municipal Executive stating that the foreign national did
not have to attend a civic integration programme under the Dutch Civic
Integration (Newcomers) Act, because the Dutch language skills of the
foreign national are sufficient;
A letter from the Municipal Executive stating that the foreign national was
not capable of following the civic integration programme under the Dutch
Civic Integration (Newcomers) Act due to psychological or physical complaints;
An extract from the Municipal Administration (GBA) showing that the
foreign national lived in the Netherlands for at least 8 years at school age
(from 5 years of age up to and including 16 years of age).
n The foreign national passed the civic integration examination abroad
evidence:
A copy of the certificate showing that the foreign national passed the civic
integration examination abroad.
Identification
Please accompany the request for advice by copies of the pages containing the identification details, stamps, travel stamps and
endorsements of the valid border-crossing document (e.g. a passport). If the foreign national is a minor child (younger than 18 years
of age) without its own valid border-crossing document: provide copies of the pages containing the identification details, stamps,
travel stamps and endorsements of the valid border-crossing document of the parent in which the name of the minor child has been
entered. It is not necessary to copy empty pages.
16
Submitting your request for advice
> Check whether you filled in the form completely.

>M
ake sure that your request for advice is accompanied by all the enclosures, evidence and documents that have been requested.
> Now place your signature on the front page of this form.
> S end the request for advice to the IND in time. Please use the return envelope and the address stickers you received together with
Do not use any staples or paperclips.
this form. Did you download this form from www.ind.nl? In that case, use an envelope of your own and write the address that
applies to your situation on the envelope.
If you are submitting the request for advice for the purpose of work as an employee/trainee/work experience, please send your
request for advice to the IND, Attn: IND-loket kennis- en arbeidsmigratie, Postbus 3022 GA Rijswijk, the Netherlands.
In all other cases you can send your request for advice to the IND, Attn: afdeling MVV, Postbus 70567, 5201 s-Hertogenbosch.
IND5003_M138/11A
Appendix
Proof of income
M138
This list states which items of evidence that demonstrate proof of income are required by
the IND for the assessment of the request for advice. The application form states in which
cases and from which person(s) you must accompany your request for advice by these items
of evidence to the income. In most cases, this proof of income must be provided by you (the
person providing residence) and your spouse, partner or registered partner.
The pieces of evidence you are submitting as a proof of your income may be copies, unless
stated otherwise.
NB. The IND may verify the correctness of the enclosed wage, employment and benefit
details at another government agency (e.g. the Netherlands Employees Insurance Agency
(UWV) or the Tax and Customs Administration).
If you or your spouse, partner or registered partner has an employment

agreement which is valid for a period of at least 1 year at the time of
submitting your application; or
If you (the foreign national) will perform activities as an employee (in the
context of an EU action programme or an international agreement to which
the Netherlands is a party)
Your current employment agreement(s);
The Appendix Employers Declaration filled in completely and signed (not
older than 3 months);
Pay slips over the past 3 months.
Only if you earn structurally more than is apparent from your employment agreement (e.g.
because of overtime)
Pay slips over the past 12 months.
The most recent benefits statement (over a period of at least 1 year

following the grant decision);
A letter from the benefits agency stating the date of re-examination.
If you or your spouse, partner or registered partner has received invalidity benefits under the
Work and Income (Capacity for Work) Act (WIA benefit) since 1 January 2006
The grant decision showing that you are unfit for work (and which
percentage);
The most recent benefit statement;
If you or your spouse, partner or registered partner is permanently unfit for work and you or
your spouse, partner or registered partner does not receive occupational disability benefits
(WAO benefits), invalidity benefits under the Work and Income (Capacity for Work) Act
(WIA benefits), benefits under the Invalidity Insurance (Self-Employed Persons) Act (WAZ
benefits), or benefits under the Invalidity Insurance (Young Disabled Persons) Act (Wajong
benefit)
A declaration from the Municipal Health Service, the company doctor, or the
medical examiner showing that you are wholly unfit for work, the date on
which you became wholly unfit for work, and what the expected duration of
the incapacity for work is;
If you or your spouse, partner or registered partner receive(s) social assistance benefits and
it is permanently impossible for you or your spouse, partner or registered partner to work
again
All grant decisions of the past 5 years and any correspondence with the
Municipal Executive about the exemption of the obligation to seek work,
and evidence showing that integration into the workforce is not to be
expected within a reasonable period of time.
If you or your spouse, partner or registered partner has an employment

agreement which is valid for a period for less than 1 year at the time of
submitting your application
Your current employment agreement(s) showing that you will have work for
at least the next 6 months;
Over the past 3 years:
- All salary statements; and
- All annual income statements; and
- All employment agreement(s) and temporary employment agreement(s)
(through an employment agency); and
- grant decision(s) and benefit slip(s).
If you or your spouse, partner or registered partner works as an agency
employee or on the basis of an on-call contract, a seasonal work contract, a
zero-hours contract, or any other employment agreement with a deferred
duty of performance
Your current employment agreement(s) or temporary employment
agreement(s) (through an employment agency) showing that you will have
work for at least the next 6 months;
Over the past 3 years:
- All salary statements; and
- All annual income statements; and
- All employment agreement(s) and temporary employment agreement(s)
(through an employment agency); and
- grant decision(s) and benefit slip(s).
If you or your spouse, partner or registered partner receives supplementary
or full benefits
If you or your spouse, partner or registered partner receives a supplementary or full benefit
payment (e.g. an unemployment benefits (WW), sickness benefits (ZW), old age benefits
(AOW), dependant's benefits (ANW), or a reintegration benefit payment (REA))
The letter of your benefits agency granting your benefit;
The most recent benefits statement;
If you or your spouse, partner or registered partner receives occupational disability benefits
(WAO benefits), benefits under the Invalidity Insurance (Self-Employed Persons) Act (WAZ
benefit), or benefits under the Invalidity Insurance (Young Disabled Persons) Act (Wajong
benefit)
The grant decision showing that you are unfit for work (and which
percentage);
If you or your spouse, partner or registered partner is a self-employed person

The Appendix Declaration of Income as a Self-Employed Person filled in
completely and signed by you and an authorised accountant (e.g. a
registered accountant, an auditor, an accounting consultant, a tax adviser of
the Dutch Federation of Tax Advisers (NFB), or a tax adviser of the Dutch Tax
Consultants Association (CB)) or an accountant with a BECON number issued
by the Tax and Customs Administration, together with the required annexes;
A recent original extract from the registration of the enterprise/company at
the Chamber of Commerce.
If you or your spouse, partner or registered partner is a director-major
shareholder
The official documents showing the percentage of your interest in the
company (percentage of ownership);
A copy of your employment agreement (or agreements, if you have several
jobs);
An original Appendix Employers Declaration filled in completely, stating
the date and provided with a signature of the employer and a company
stamp (not older than 3 months);
Information about the 3 months prior to the date of your application
showing that you received a monthly salary (salary slips, bank statements);
Proof that the wage tax that was withheld by the company was paid to the
Tax and Customs Administration (bank statement).
As an unpaid research worker
If you receive sponsor money: evidence showing the amount of money you
receive and the duration of the sponsor agreement; or
If you receive periodic payments to pay for your stay in the Netherlands:
proof of these payments; or
If you have paid work abroad: a copy of an employment agreement with the
current employer abroad.
BE01/11A
Appendix
Employers Declaration
M138
If you have several employers, please copy this appendix. Fill in and sign one copy for each
employer. The request for advice states in which cases and from which person(s) you must
enclose an Employers Declaration with your request for advice.
NB. The IND may verify the correctness of the enclosed wage, employment and benefit
details at another government agency (e.g. the Netherlands Employees Insurance Agency
(UWV) or the Tax and Customs Administration).
Details of the employee
1.1 Citizen Service Number

(BSN)
1.2 Name
| |
1.3 Gender
n Male n Female
First names
Street
1.4 Home address
Number
|
Postal code

Day
month
City/Town
year
1.5 Date of birth

1.6 Place of birth
1.8 Nationality
Details of the company/institution
2.1 Name
|
Street
2.2 Visiting address
Number
|
Postal code
City/Town
2.3 Withholding tax number
Employment details
3.1 Employees job title
|
Day
month
year
3.2 Date of employment

3.3 Type of employment
n Fixed employment
3.4 Employment period
n Indefinite period, or
n Definite period
n On-call contract
Day
n Ongoing temporary work
month
from
year

BE02/11A
to
Day
month
year
2 van 2
3.5 Is there a provision for continued
payment of wages during the
term of the agreement if there is
not any work?
n No
3.6 Trial period
n No
n Yes
Day
month
year
n Yes, until
Hours per week (contractual) Hours per week (actual)
3.7 Working hours per week

3.8 Gross salary (excluding holiday
allowance)
3.9 Wage for social security purposes
(excluding holiday allowance)
3.10 Net salary (excluding holiday
allowance)
n Per month, or
n Per month, or
All amounts rounded to the nearest full euro
n per 4 weeks
n per 4 weeks
3.11 Percentage of holiday allowance
n per 4 weeks
n Per month, or
Signature of the employer

I declare that the above-mentioned employee has been employed by the above-mentioned company/institution.
I have filled in this form truthfully.
4.1 Name
4.2 Job title

City/Town
4.4 City/Town and date
4.5 Signature
4.6 Stamp of company/institution
BE02/11A
Day
month
year
Appendix
Sponsor and Awareness Declaration
Concerning the Stay with Religious
or Ideological Organisations
M138
Only fill in this declaration if you are submitting an application for a residence permit for
a stay on religious or ideological grounds. Fill in and sign the declaration and submit it
together with your request for advice.
Details of the foreign national

The undersigned, further referred to as the representative of the organisation, hereby declares with regard to the foreign nationals
intended stay at the organisation:
1.1 V-number
First names
1.2 Name
| |
1.3 Gender
n Male n Female
1.4 Date of birth

1.5 Nationality
Day
month
year
The representative of the organisation is aware of the following:

A stay of the above-mentioned foreign national with the organisation in the
Netherlands will only be permitted for religious or ideological purposes;
The foreign national is not permitted to perform work;
By virtue of the restriction under which the residence permit is granted,
it is expected that the foreign national or the organisation will inform the
Immigration and Naturalisation Service (IND) if the actual activities prove
to be different from the envisaged purpose of stay;
In the context of the monitoring of foreign nationals, the Aliens Police may
visit the organisation and the foreign national or call up the organisation
or the foreign national for a specific cause or for a random check.
The representative of the organisation declares:
That substantial recruiting activities have been performed as a result of
which it became evident that it is necessary for the foreign national to stay
in the Netherlands to meet the need of the organisation;
Nationality
|
That the cost, excluding costs of social assistance, that are incurred by
the State and other public bodies in respect of the foreign national's stay,
including the costs of the journey of the foreign national to a place outside
the Netherlands where his/her admittance is guaranteed, up to an annual
maximum amount of 5,000, may be recovered from the organisation;
If the foreign national receives benefits pursuant to the Dutch Social
Assistance Act, or the Dutch Work and Social Assistance Act as from
1 January 2004 respectively, the costs of social assistance that will have
been incurred in connection with the benefit payments to the foreign
national (related to the amount of the current benefits in accordance with
the standard of the Dutch Social Assistance Act, or the Dutch Work and
Social Assistance Act as from 1 January 2004, respectively), in addition to
the above-mentioned annual amount of 5,000, will be recovered from the
organisation.
Details of the organisation

Street
|
Postal code

2.3 Name and position of

the representative
Number
City/Town
Name
Position
| |
City/Town
2.5 Signature
|
BE06/11A
Day
month
year
Appendix
Awareness Declaration Regarding
the Transitional Regime on Religious
or Ideological Grounds
M138
a stay on religious or ideological grounds. Fill in and sign the declaration and submit it
together with your request for advice.
1.1 V-number
First names
1.2 Name
| |
1.3 Gender
n Male n Female
Street
1.4 Home address
Number
|
Postal code

Day
month
City/Town
year
1.5 Date of birth

1.6 Place of birth
1.8 Nationality
|
The undersigned hereby declares to be familiar with the fact that:
The residence permit will only be granted to him/her for a definite period of time for a stay on religious or ideological grounds with:

The residence permit will only be granted as long as he/she stays with the religious or ideological organisation for religious or
ideological purposes, and he/she is to leave the Netherlands as soon as this purpose no longer exists;
He/she is not permitted, during the stay in the Netherlands, to perform activities other than those for which he/she was granted
a residence permit.
Signature
I have filled in this form truthfully.
City/Town
2.2 Signature
BE07/11A
Day
month
year
Appendix
Medical information disclosure
consent form
M138
Information for the foreign national: If you have more than two doctors/professionals 1
in charge of your treatment, you are requested to copy this appendix, so that you can fill in
more than one consent form.
1
The doctor(s)/professional(s) in charge of your treatment must be listed in the BIG-register
or in the register of the NIP.
2
If the applicant is 12 years of age or younger or incapable of performing legal acts, this
appendix must be filled in by the legal representative. If the applicant is older than 12 years
of age but younger than 16 years of age, this appendix must be filled in by the foreign
national and his/her legal representative. If the applicant is 16 years of age or older, this
appendix must be filled in by the foreign national.
Medical Examination
1. The undersigned hereby declares to have no objection to fact that the medical advisor of the Immigration and Naturalisation
Service of the Ministry of the Interior and Kingdom Relations (hereinafter: "IND") will ask for information about his/her state
of health from the doctor(s)/professional(s) in charge of his/her treatment in connection with an investigation into the medical
circumstances around his/her residence status in the Netherlands.
2. The undersigned grants permission to send this completed consent form in copy form to the doctors/care workers to be contacted.
3. The undersigned also gives his/her consent to the medical advisor to provide his/her medical information to a medical specialist
that may be engaged in any further investigation.
4. The undersigned authorises the following doctor(s)/professional(s) in charge of his/her treatment who are listed in the
BIG-register (pursuant to the Dutch Individual Healthcare Professionals Act (BIG)) and/or at the NIP (the Dutch professional
association of psychologists) (doctors, dentists, physiotherapists, midwives, nurses, pharmacists, healthcare psychologists,
psychotherapists, and special educators) to provide information to the medical advisor of the IND. The undersigned declares to
be aware that this consent form will be stored in digital form.
1.1 V-number
1.2 Name
First names
| |
Day
month
year
1.3 Date of birth
Signature
2.1 Name of the foreign

national 2
2.3 Signature of the

foreign national
2.4 Name of the legal

representative 2
2.6 Signature of the legal

representative
City/Town
City/Town
BM39A/11A
Day
month
year
Day
month
year
2 van 2
Details of the doctor/professional in charge of the treatment
3.1 Name of the GP/

COA-doctor/specialist 1
3.2 Name of the hospital/

practice/institution
n GP
n COA-doctor n Specialist
Street
Postal code
Number
City/Town

3.1 Name of the GP/

COA-doctor/specialist 1
3.2 Name of the hospital/

practice/institution
n GP
n COA-doctor n Specialist
Street
Postal code
Number
City/Town
Passing on the medical advice

The undersigned gives consent to the medical advisor of the IND to provide the medical advice to the civil servants of the
Immigration and Naturalisation Service who are responsible for decision-making, to the civil servants of the Repatriation &
Departure Service to enable medical arrangements to be made before, during or after removal, to the relevant legal experts
of the office of the State Advocate, and to the bodies assigned by law for the administration of justice.
4.1 Name of the foreign

national 2

foreign national
4.4 Name of the legal

representative 2
4.6 Signature of the legal

representative
City/Town
City/Town
BM39A/11A
Day
month
year
Day
month
year
Appendix
Sponsor declaration
M138
Only have this declaration filled in if you are submitting a request for advice for a stay:
With your unmarried partner;
With your child;
As a foster child;
As a family member (other than child/parent);
For a family visit;
For study purposes;
As an au pair;
To undergo medical treatment
As an dependent family member of someone who is working for an international
organisation and does not have sufficient means of existence himself/herself.
Fill in and sign the declaration and submit it in together with your application.
If the guarantor and his/her partner are both Dutch nationals, please accompany your
application with copies of their valid identification documents. If either of the two has a
different nationality: a copy of the valid border-crossing document in which the residence
permit has been recorded or a copy of the front and back of the residence permit. If the
guarantor is not your sponsor /(person providing residence), please accompany a copy of the
valid identification document of this guarantor. This is not necessary if this guarantor fills in
and signs this sponsor declaration on behalf of an organisation or institution.
The undersigned acts as a guarantor for the costs incurred by the State and
other public bodies as a result of the foreign nationals stay in the Netherlands
for a period of five years. The guarantee will end if sufficient security has been
provided otherwise, if the foreign national has left the Netherlands permanently,
if the foreign national has been granted a residence permit for another purpose
or a permanent residence permit, or if the foreign national has become a Dutch
national. In addition, the undersigned declares that the cost, excluding costs of
social assistance, that are incurred by the State and other public bodies in
respect of the foreign national's stay, including the costs of journey of the
foreign national to a place outside the Netherlands where his/her admittance is

guaranteed, up to an annual maximum amount of 5,000, may be recovered
from the guarantor. In addition, the undersigned declares to be familiar with
the fact that, if the foreign national receives a benefit payment pursuant to the
Dutch Work and Social Assistance Act, the costs of social assistance that will
have been incurred in connection with the benefits paid to the foreign national
(related to the amount of the current benefits in accordance with the standard
of the Dutch Work and Social Assistance Act) in addition to the abovementioned annual amount of 5,000, will be recovered from the guarantor.
1.1 V-number
1.2 Name
First names
| |

1.3 Gender
1.4 Date of birth
n Male n Female
month
Date of birth
First names
| |
Street
2.2 Home address
Number
|
Postal code
year
Details of the guarantor

2.1 Name
Day
City/Town
Signature
City/Town

guarantor
3.3 Signature of the partner

of the guarantor
Day
month
> If you are a marriage partner, registered partner, or partner, your partner must also sign for approval.
BM47/11A
year
Appendix
Exchange Organisation
Sponsor Declaration
M138
exchange purposes. Fill in and sign the declaration and submit it in together with your
request for advice.
The undersigned, as a representative of the exchange organisation, guarantees
that the following cumulative conditions are fulfilled in view of the stay in the
Netherlands of the foreign national (mentioned below) in the context of its
exchange programme:
The foreign national is not younger than 15 years of age, but not older than
26 years of age;
The foreign national will have a valid passport during the stay;
The foreign national has never stayed in the Netherlands before on the basis
of a residence permit;
The foreign national has never had an employment relationship with the
host family before, when residing abroad;
The foreign national is unmarried and is not providing for dependent family
members;
The foreign national does not pose a danger to public order and national
security;
The foreign national will undergo an tuberculosis test (if applicable).
The organisation acts as a guarantor for the following:

The costs ensuing from the foreign national's stay in the Netherlands and
his/her departure from the Netherlands (whether this departure is forced or
not);
Taking out adequate insurance against medical expenses and insurance
against third-party liability;
Informing the Aliens Police and the Immigration and Naturalisation Service
(IND) immediately of any change (e.g. change of address or change of host
family);
Ensuring that the foreign national is not permitted to perform paid work and
that any voluntary work will not be performed without a work permit (for
non EU citizens) having been issued;
The timely return of the foreign national, which return may in any case
not be later than one year after the arrival of the foreign national in the
Netherlands.

1.1 Name
First names
| |
Day
month
year
1.2 Date of birth

1.3 Nationality
Details of the exchange organisation

2.2 City/Town
2.3 Name of the contact

person
2.4 Employees job title
Signature
City/Town

exchange organisation
BM48/11A
Day
month
year
Appendix
Declaration of Income as
a Self-Employed Person
M138
By means of this form, several questions are asked about the income of the
foreign national or of the person who has an interest in the fact that a residence
permit is granted to a foreign national. On the basis of your answers, a decision
will be made on whether the person involved permanently and independently
has sufficient means of existence within the meaning of the Dutch Aliens Act
2000.
Only have this declaration filled in and signed by an accountant if you are submitting an
application for a residence permit and you or the person providing residence has an income
as a self-employed person. Accompany the declaration filled in and signed by you and your
accountant with your request for advice.
NB. The IND can verify the correctness of this declaration at another government agency
(e.g. the Netherlands Employees Insurance Agency (UWV) or the Tax and Customs
Administration).
1
1.1 Professional title
Details of the accountant

n Tax Advisor from the Netherlands Tax Consultants Association
n Chartered accountant n Accounting consultant
n Tax Advisor from the Dutch Federation of Tax Advisors

n NOAB Advisor n Other, namely:
|
1.2 BECON number Tax Office
| 1.3
Telephone number
Street
|
Postal code
Number
City/Town
Details of the self-employed person
2.1 V-number
2.2 Name
First names
| |
Street
2.3 Home address
Number
|
Postal code

Day
month
City/Town
year
2.4 Date of birth

2.5 Place of birth
2.6 Nationality
2.7 Name of the enterprise
|
Street
|
Postal code
City/Town
2.9 Registration number with

the Chamber of Commerce
BM57/11A
Number
2 van 2
NB. The profit of the past financial year or the current financial year of the
enterprise is calculated by decreasing the sum of the operating income by the
sum of the operating costs. The income and costs must be calculated in
accordance with the commercial principles. Please also note the following in
this respect. If there is no past financial year, the calculation of the monthly
profit must be made on the basis of the so-called permanence rule.

This involves the stipulation that both the operating income and the operating
costs must be attributable to the relevant period. If the enterprise has the form
of a partnership, a general partnership, or a limited partnership, the profit is
distributed among the relevant partners.
Income from business activities
Current financial year, immediately preceding

the date on which the application was submitted
Day
month
year
3.2

3.3

Profit or profit share from the business activities over the

above-mentioned period (see explanation)
Amount to mentioned at 3.2 divided by the number of
months stated
month
year
Day
month
year
Last closed financial year, immediately preceding

the date on which the application was submitted
Day
month
year
3.4 Financial year (from-to)

3.5

3.6

3.7

3.8
Day
3.1 The data included at 3.2 and 3.3 relate to the period (from-to)
Profit or profit share from the business activities

in conformity with the annual accounts (see explanation)
Amount mentioned at 3.5 divided by the number of
months in the last closed financial year
Adjustments to the above-mentioned profit or profit
share from the business activities before taxable profit*
Taxable profit*
3.9 Processing status of return by Tax and Customs Administration
> Tick one situation only and enclose the relevant document with your application
n Proof that the tax return has been received by the Tax and Customs Administration
> For a sole-trader, attach IB-60
n Provisional assessment > Attach provisional assessment
n Final assessment > Attach final assessment
3.10 If the Tax and Customs Administration has already imposed an
assessment, did it base its assessment on the profit from business n Yes
n No
activities stated?
>
Second but last closed financial year
month
Day
Attach an explanation on a separate annex

year
Day
month
year
3.11 Financial year (from-to)

3.12 Profit or profit share from the business activities

in conformity with the annual accounts (see explanation)
3.13 Amount mentioned at 3.5 divided by the number of

months in the last closed financial year
3.14 Adjustments to the above-mentioned profit or profit

share from the business activities before taxable profit*
3.15 Taxable profit*
3.16 Processing status of return by Tax and Customs Administration
> Tick one situation only and enclose the relevant document with your application
n Proof that the tax return has been received by the Tax and Customs Administration
> For a sole-trader, attach IB-60
n Provisional assessment > Attach provisional assessment
n Final assessment > Attach final assessment
3.17 If the Tax and Customs Administration has already imposed an
assessment, did it base its assessment on the profit from business n Yes
n No
activities stated?
>
Attach an explanation on a separate annex
(*required only for verification purposes by the IND)
Signature
The accountant hereby truthfully declares that the worker on a self-employed basis has earned an income from business activities in
accordance with the data filled in on this form.
City/Town
4.2 Signature Entrepreneur
|
City/Town
4.4 Signature Accountant
BM57/11A
Day
month
year
Day
month
year
Where to send your request for advice?

Select the address label that applies to your situation and put it in the designated place on
the return envelope.
Are you submitting your request for advice for the purpose of employment/traineeship/
work experience?
YES
NO
>
Immigratie- en Naturalisatiedienst
t.a.v. IND-loket kennis- en arbeidsmigratie
Postbus 3022
2280 GA RIJSWIJK
>
Immigratie- en Naturalisatiedienst
t.a.v. afdeling mvv
Postbus 70567
5201 CZ S-HERTOGENBOSCH

Application For Dutch Provisional Residence Permit MVV

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Application For Dutch Provisional Residence Permit MVV

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Request for Advice

Preceding the Actual Application

Signature of the sponsor (the person providing residence)

City/Town and date

| | I submit this form and

What will happen with your request for advice?

Your employer will apply for a work permit at UWV WERKbedrijf.

What must the foreign national do?

Language of the documents to be enclosed

Why is an MVV required?

Work permit (twv)

Request for Advice

Details of the sponsor (the person providing residence)

1.1 Citizen Service Number

Surname as it appears in your passport or on your identity papers

1.4 Home address

1.5 Date of birth

1.7 Country of birth

1.9 Civil status

1.10 Telephone number

1.12 Residence status

n Awaiting the outcome of an application for a residence permit

> Fill in only in cases of

1.13 Name of the organisation |

Details of the foreign national (abroad)

2.3 Home address

2.4 Date of birth

2.6 Country of birth

2.8 Telephone number

2.10 Embassy or consulate

Purpose of stay in the Netherlands

n For study purposes

n To work on the basis of an international treaty

Provisional Residence Permit for Stay with a relative or a family member

If it concerns a marriage, you must also submit the following:

Request for Advice

Request for Advice

Regular Provisional Residence Permit to work as an employee

Evidence of the foreign nationals employment history on board a Dutch

Regular Provisional Residence Permit to work as a border-crossing service provider

n To work as a border-crossing service provider

Regular Provisional Residence Permit to work on a self-employed basis

n To work on a self-employed basis

Regular Provisional Residence Permit to work on the basis of an international treaty

Request for Advice

9 Regular Provisional Residence Permit to attend a Secondary Education Course or

Regular Provisional Residence Permit for Exchange Purposes

n Exchange on the basis of the Working Holiday Scheme or Working

Regular Provisional Residence Permit as an Au Pair

12 Regular Provisional Residence Permit to Stay in the Netherlands with a Religious or

Regular Provisional Residence Permit to Undergo Medical Treatment

n To undergo medical treatment

Civic Integration Examination Abroad

Request for Advice

Submitting your request for advice

> Check whether you filled in the form completely.

Do not use any staples or paperclips.

If you or your spouse, partner or registered partner has an employment

The most recent benefits statement (over a period of at least 1 year

If you or your spouse, partner or registered partner has an employment

If you or your spouse, partner or registered partner is a self-employed person

Details of the employee

1.1 Citizen Service Number

> Fill in only in cases of

2.10 Embassy or consulate

n For study purposes

n To work on the basis of an international treaty

Evidence of the foreign nationals employment history on board a Dutch

n To work as a border-crossing service provider

n To work on a self-employed basis

9 Regular Provisional Residence Permit to attend a Secondary Education Course or

n Exchange on the basis of the Working Holiday Scheme or Working

12 Regular Provisional Residence Permit to Stay in the Netherlands with a Religious or

n To undergo medical treatment

The most recent benefits statement (over a period of at least 1 year

3.2 Signature of the

3.3 Signature of the partner