Emigration Explanation •• Only when your application is received before your date of emigration, it will be processed with that date. •• Visiting address: utrecht.nl/bz 1 Enclose the relevant documentary evidence where requested on the form, marked with this icon What are your personal data? Male Female Family name Given names Date of birth Place of birth Email address Copy of valid identification 2 Old address? Street No. Postal code City 3 New address? Street No. Postal code City Country Date of emigration pto Enclose the relevant documentary evidence where requested on the form, marked with this icon 4 Other members of your family leaving with you You are allowed to submit the emigration for: •• your spouse; •• your civil partner; •• your child(ren); •• your parent(s). Every other person emigrating with you except te ones mentioned on the left, have to submit their own emigration (even if you are not married and have a cohabitation contract). Family name 5 Initial(s) Date of birth m/f Initial(s) Date of birth m/f Persons staying at the old address Family name Signature Signature Place Date Signature Send to Privacy Gemeente Utrecht Publiekszaken Team 2 PO Box 5000 3502 JA Utrecht The administration and submission of your personal data is in accordance with the dutch law ‘Wet Bescherming Persoonsgegevens’. More information: rijksoverheid.nl/persoonsgegevens