Higher Education Bursary Fund 2016/17

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1 Received: Date By Receipt No: Part 1: Your Personal Details PLEASE WRITE CLEARLY Higher Education Bursary Fund 2016/17 Forename... Surname... Date of Birth.../.../... Enrolment Number... Address......Post Code... Mobile Phone Number... Home Phone Number... Course Title... (IF YOU ARE A FULL TIME STUDENT, you will need to have taken out your full student loan to be able to apply to the HE Fund) Part 2: Living Arrangements Please state who you live with; Alone With your partner/spouse In shared accommodation With parents or guardian Other (please state) Do you share all household expenses? Yes No

2 Part 3: Income Details You must provide evidence of your income. As part of our assessment process we may ask for further evidence to support your application. Your application will be assessed on the total amount of income, including earned income, working and child tax credits, pensions and any other benefits you receive. Please indicate ALL of the income/benefit you receive in the table below, and provide the evidence for each one. (We will disregard income from Child Benefit and Disability Living Allowance (PIP)). Income Received Evidence Required Employment (includes paid and self-employment) P60 for 2015/16 tax year or SA302 (copy of self-employment accounts certified by Accountant) Means Tested Benefits (includes Universal Credit, Job Seekers Allowance, Income Support, Working/Child Tax Credit, Housing and Council Tax Benefit etc.) Non-Means Tested Benefits (includes Employment & Support Allowance, Disability Living Allowance/Personal Independence Payment, Carers Allowance, Incapacity Benefit etc.) Pensions and other benefits not included above TO BE COMPLETED BY ALL STUDENTS Part 4: Disability Original current 2016 benefit letter showing the full amount of benefit awarded Original current 2016 benefit letter showing the full amount of benefit awarded Pension Statement for 2015/16. Original current 2016 benefit letter showing the full amount of benefit awarded Do you have a disability (physical/mental health condition dyslexia)? Yes No Have you applied for Disabled Students Allowance (DSA)? Yes No Do you wish to apply for any financial assistance towards any special equipment/material not covered by DSA or assistance towards the cost of a diagnostic test (e.g. dyslexic students)? Yes No If yes, please give details below continue & attach a separate sheet if needed Part 5: Supporting Statement Use this space to state your reason for your application & any specific costs - attach another sheet if you need to. If you are a lone parent, in receipt of the maximum grant & need help with childcare costs please state your costs and submit your contract from your childcare provider.

3 Part 6: Declaration (i) I am a UK National/British citizen; or (ii) I am an EU National who has been ordinarily resident in the UK for the three years prior to the first day of the first academic year of my course, or (iii) I am settled within the United Kingdom (UK) (i.e. have the Right to Abode in the UK or have been awarded Indefinite Leave to Enter Remain, please provide the reference number from your UKBA award notice and submit a photocopy of that award notice) or (iv)i have been recognised by the UK Government as a Refugee ( please provide the reference number from your UKBA award notice giving the expiry date of your status and submit a photocopy of that award notice) or (v)i have been granted Humanitarian Protection (HP) by the Home Office ( please provide the reference number from your UKBA award notice giving the expiry date of your status and submit a photocopy of that award notice) or (vi)i am an EEA or Swiss Migrant Worker or the family member of an EEA or Swiss Migrant Worker Please tick if you intend to continue working while studying or (vii)i am the child of a Swiss national or (viii)i am the child of Turkish worker Section B; I confirm that I am applying for a short-term/stop gap loan because of a delay in the assessment of my student finance entitlement or for childcare costs and I am not in default of a previous student loan I confirm that I am registered and in attendance on the course described in this form I confirm that I am not living with a spouse/partner ALL STUDENTS WILL NEED TO PROVIDE COPIES OF DOCUMENTS 1-6 FROM THE CHECKLIST BELOW (as applicable). YOUR APPLICATION WILL BE RETURNED IF YOU DO NOT INCLUDE THE DOCUMENTS BELOW Student Checklist 1. SFE support notification, loan request & payment schedule letter 2. Bank/Building Society statements for last 3 months must show payment of Student Loan 3. Evidence of benefits claimed 4. Partner/Spouse net income- e.g. P60, Benefit Letter (Please Tick)

4 I declare that the information that I have given on this form is correct and complete to the best of my knowledge. I understand that giving false information will automatically disqualify my application and may also lead to disciplinary procedures resulting in possible expulsion from the College. I further undertake to repay any loans/grants obtained by me as a result. Your name (print); Signature;... Date;..

5 WALSALL COLLEGE HE FUND BANK DETAILS FORM Please complete this form clearly and accurately to enable us to process payments direct to your bank account via the BACS payment system. Any mistakes will result in a delay to your payment. You must advise us, in writing if you close this account to ensure that we hold your correct bank account details. Please provide a recent bank statement so that we can check that all the details are correct. Full Name Enrolment Number Bank Name and Address Name of Account Holder Bank Sort Code Bank Account Number Building Society Roll Number DATA PROTECTION ACT 1998 In accordance with the requirements of the Data Protection Act 1998, Walsall College has a duty to protect the personal data it processes. To comply with this legislation, information must be collected and used fairly, stored safely and not disclosed to any person unlawfully. This is outlined in our Data Protection policy, a copy of which can be obtained from the Data Protection Officer. Use of personal data contained within this form will only be used for its intended purpose and in accordance with the College Data Protection Act 1998 registration. We will not release any personal information to 3 rd party organisations without obtaining your written consent.