DEPARTURE FROM THE NETHERLANDS

City Hall:
Postal address

Coolsingel 40
P.O. Box 70013
3000 KR Rotterdam
Phone number 14010
Fax
010-267 2562

(vertrek naar het buitenland)

E-mail
infopzr@rotterdam.nl
Internet

Mutatiedatum

www.rotterdam.nl

:

____________
Datum geldigheid

:

____________
Paraaf

:

____________

Surname

: ______________________________________________________________

First name(s) (in full) : ______________________________________________________________
BSN

: _________________________Phone : ______________________________

E-mail

: _____________________________________________________________

Place and date of birth :____ / ____ / ________ in _________________________________________
will you be staying abroad for at least two-thirds of the year (= 8 months) o Yes o No

Previous address in Rotterdam
Address:: ___________________________________________________ House number: _________

New address
Departure date

: ____ / ____ / ________

Address

: _____________________________________________________________

Place of residence

: _____________________________________________________________

Country

: _________________________ Phone: _____________________________

The following family members (spouse / registered partner / children) will move too:
1. ___________________________________________________ Date of birth: ____ / ____ / ______
2. ___________________________________________________ Date of birth: ____ / ____ / ______
3. ___________________________________________________ Date of birth: ____ / ____ / ______

Will someone be staying at the previous address?

O No

O Yes, namely

1. ___________________________________________________ Date of birth: ____ / ____ / ______
2. ___________________________________________________ Date of birth: ____ / ____ / ______
Date

: ____ / ____ / ________

pzr084 (02-12) .Signature 1 : ________________________________________________ 1 Enclose (a copy of) a valid identity card 2 Unmarried couples have to report their departure individually.