Application For Discretionary Funds (Scotland) (updated May 2014)

Transcription

1 Application For Discretionary Funds (Scotland) (updated May 2014) Please read the guidance notes carefully to help you complete this application. SECTION 1: Your Details Open University Personal Identifier Postcode Title Forename(s) Surname Please provide a current address if you have one, this is how we will contact you if we have any queries. 1.1 Please detail the module(s) you are currently studying below. Module code Start date (month/year) Module title Credits 1.2 I confirm that I am registered on and actively participating in the module(s) I ve detailed in section Do you meet the eligibility criteria listed in Section 1.3 of the guidance notes? If you answer no, you are not eligible for support. Please be sure that you read the residency criteria carefully.

2 SECTION 2: Disabled Students Allowance (DSA) Disabled Students Allowance is available to students with a disability to help with extra study costs (see section 2.1 of the guidance notes) 2.1 Have you applied for a Disabled Students Allowance (DSA)? SECTION 3: Household 3.1 Please provide details of other adults (aged 18 and over) who live in your household. Please state each person s relationship to you (e.g. husband, wife, civil partner, partner, adult son or daughter, parent, lodger, co-tenant) Name Age Relationship to you 3.2 Do you, your spouse or partner have any children (aged under 18) for whom you are totally or mainly financially responsible? Please provide details below: Child s full name Date of birth rmally living with you?

3 SECTION 4: Income & Expenditure 4.1 Household Income Please provide details of your monthly net household income (after tax). You must list all money coming into your household, including that of yourself and your partner. If you have no income in a particular category or categories, please write NIL in the box. Type of Income You Monthly Net Your husband, wife or partner Monthly Net Paid employment Self-employment Pension Investment Income (e.g.trusts, shares) Interest from bank/savings accounts Income from grants/scholarships Income Support Employment & Support Allowance Jobseekers Allowance Housing Benefit Council Tax Benefit Working Tax Credit Child Tax Credit Other income (please specify) Total Income You must provide up to date evidence of all the items listed above. The income evidence you provide must match the income you declare. (see section 4.1 of the guidance notes for further information)

4 4.2 Household Expenditure Please provide details of your monthly household expenditure. If you have no expenditure in a particular category or categories, please write NIL in the box. (see section 4.2 of the guidance notes for further information) Rent Mortgage (Including Building Insurance) Council Tax Childcare Travel Course Fees (ousba only) Total Other Expenditure Please provide details of any additional monthly expenditure, i.e, loans, credit card or other debt. Item Total Debt Monthly Payment Total If you listed any items in other expenditure above, please provide details of how they arose and the measures you are taking to reduce them. You must provide up to date evidence of all the items listed above.

5 4.3 Please use the space below to provide any additional information you wish to be taken into consideration when your application is assessed. Section 5: Support 5.1 Please list the type of support you wish to apply for below. Please provide as much detail as possible and include appropriate evidence. If this section is not completed we will have to return your form. Type of support Amount requested Evidence provided Example: Travel to 3 tutorials 15 Print out of fare cost from internet or copy of a previous ticket

6 SECTION 6: Declarations 6.1 Declaration Please read the declaration below carefully. You must sign and date the declaration(s) so that your application can be processed. The information I have given on this form is complete and accurate to the best of my knowledge and I will inform the Open University immediately of any change in my circumstances, at any time, that might affect my entitlement to support. I understand that if I give the Open University false information, this will automatically disqualify my application and also may lead to disciplinary procedures resulting in possible explusion from the University. I further undertake to repay any money obtained by me as a result. I understand that the Open University may ask for further evidence in support of claims made in this application. Your Signature Name (please print) Date 6.2 Declaration by your husband, wife or partner for whom financial information has been provided: The information I have given on this form is complete and accurate to the best of my knowledge and belief. I will inform the Open University immediately of any change in my circumstances, at any time, that might affect this application for support. I agree to supply any further information the Open University asks for in relation to this application. I understand that if I give the Open University false information, or fail to give complete information, I may be prosecuted. Signed Name (please print) Date Please return your completed application and supporting evidence to: Student Registration Scotland The Open University in Scotland 10 Drumsheugh Gardens Edinburgh EH3 7QJ We expect to take up to 21 days to process your application from the date we receive it. Please don t contact us to check on the progress. We will write to you with the outcome once your application has been assessed.