Form FLR(S) - UK Border Agency - the Home Office

SECTION 13 ~ DeclarationYou must now read the declaration below and sign it. It must be signed by you(the applicant) and not by a representative or other person acting on yourbehalf. If you are under the age of 18, your parent or legal guardian maycomplete the application form and sign the declaration on your behalf.I hereby apply for leave to remain in the United Kingdom as a stateless personfor myself and any dependants listed in this form. The information I have given iscomplete and is true to the best of my knowledge. I also declare that thephotograph(s) submitted with this form is/are a true likeness of me and of thedependants included in the application, as named on the back of eachphotograph.I confirm that if, before this application is decided, there is a material change inmy circumstances or new information relevant to this application becomesavailable I will inform the Home Office.I understand that all information given by me will be treated in confidence butmay be disclosed to other government departments, agencies, local authoritiesand other bodies to enable them to carry out their functions. I understand thatthe Home Office will normally seek my consent before making enquiries of thoseauthorities which may be necessary in order to reach a decision on myapplication.If my application is unsuccessful and I am to be removed from the UnitedKingdom, I understand that it may be necessary for the Home Office to provideinformation about my identity to the authorities in the country of re-admission,solely in order to obtain travel documentation.I understand that my details may in certain circumstances be passed to other people,including fraud prevention agencies, to prevent and detect fraud, money laundering andother crimes. I also understand that the Home Office may receive information about me.Further details explaining when information may be passed to or from other people,including fraud prevention agencies, and how that information may be used can beobtained from the UK Border Agency/Home Office website.I am aware that it is an offence under the Immigration Act 1971, as amendedby the Immigration and Asylum Act 1999 and the Nationality, Immigrationand Asylum Act 2002, to make to a person acting in execution of any ofthose Acts a statement or representation which I know to be false or do notbelieve to be true, or to obtain or seek to obtain leave to remain in theUnited Kingdom by means which include deception.Signed: ___________________________________________Date: __________________________________STATELESS LEAVE APPLICATION FORM Version 03/2013 – page 23 of 33