16 19 Bursary Application Form: Student Section (A)

Transcription

1 16 19 Bursary Application Form: Student Section (A) There are 3 main sections to this form please read the questions carefully before answering. Completed forms need to be sent along with any supporting evidence to Mrs L Walker at Northgate High School. Student Details answer all of the questions below and sign the declaration A6. A1 Name Surname/Family name A2 of birth / / A3 Home address Postcode Phone number I will be applying/have already applied for a Suffolk County Council travel pass Yes/No A4 Bank or Building Society account details Full name of account holder Name of Bank/ Building Society Branch Sort Code Account Number Roll Number (Building Society) This should be the name as it appears on your cash/debit card, or statement This may not be the same as your cash or debit card number; you can find it on your statement and it is usually 8 digits long A5 Eligibility Tick the answer that applies to your personal situation (a) I am a young person in Care (including Foster Care) I am a Care Leaver I receive Universal Credit and live independently of my parents I am a disabled young person who receives both Employment Support Allowance and a Personal Independence Payment If you received Income Support, please complete Benefits Income (C), questions C1, C2 and C5. 1

2 A5 Eligibility Tick the answer that applies to your personal situation (b) I am a British Citizen/EU national and have been living in Britain/EU for the past 3 years I have settled status and have been ordinarily in the UK for the past 3 years I am recognised as a refugee by the UK government None of the other 3 options listed in part (b) Privacy notice The information that you provide on this form will be used to assess your eligibility for a Bursary payment. This information may be shared with other organisations for administration and statistical purposes; these could include the Education Funding Agency for England, the Department for Education and Suffolk County Council. Northgate High School and Sixth Form is registered under the Data Protection Act Attendance and Progress Part of your bursary is subject to certain conditions, as stated below: You will have no unauthorised absence for the period covered by the payment. You will maintain an overall attendance of 90% over the half term. You will achieve a satisfactory level of progress. If you are failing to achieve expected standards this will be highlighted by the Sixth Form team & you will be given the opportunity to discuss & agree on the way forward. Failure to meet these conditions could result in the attendance and/or progress part of your bursary being reduced or stopped. Declaration If you give false or incomplete information, you may be prosecuted. I have read and understood these questions and the Privacy Notice above and declare that the information given on this form is correct and complete to the best of my knowledge and belief. I understand that: If I leave Northgate I will not be eligible to receive further payments from Northgate and may need to repay a proportion, or in exceptional cases all of the money paid to me as part of this scheme. I am not allowed to receive bursary payments at the same time as any other government training or learning allowance (this does not include Income Support). The information I have given may be shared with other agencies or organisations, as allowed by the law, for the purpose of checking my application and/or the prevention of fraud. A6 Signature By submitting this form and applying for a bursary you are agreeing to all of the statements and conditions above. 2

3 16 19 Bursary Application Form: Student Section (FSM) for students in receipt of Free School Meals Please read the questions carefully before answering. Completed forms need to be sent to Mrs L Walker at Northgate High School please note, Northgate will be able to check eligibility for FSM. Student Details answer all of the questions below and sign the declaration FSM6. FSM1 Name Surname/Family name FSM2 of birth / / FSM3 Home address Phone number Postcode I will be applying/have already applied for a Suffolk County Council travel pass Yes/No FSM4 Bank or Building Society account details Full name of account holder Name of Bank/ Building Society Branch Sort Code Account Number Roll Number (Building Society) This should be the name as it appears on your cash/debit card, or statement This may not the same as your cash or debit card number; you can find it on your statement and it is usually 8 digits long FSM5 Eligibility Tick the answer that applies to your personal situation (a) I confirm I am currently eligible for Free School Meals 3

4 FSM5 Eligibility Tick the answer that applies to your personal situation (b) I am a British Citizen/EU national and have been living in Britain/EU for the past 3 years I have settled status and have been ordinarily in the UK for the past 3 years I am recognised as a refugee by the UK government None of the other 3 options listed in part (b) Privacy notice The information that you provide on this form will be used to assess your eligibility for a Bursary payment. This information may be shared with other organisations for administration and statistical purposes; these could include the Education Funding Agency for England, the Department for Education and Suffolk County Council. Northgate High School and Sixth Form is registered under the Data Protection Act Attendance and Progress Part of your bursary is subject to certain conditions, as stated below: You will have no unauthorised absence for the period covered by the payment. You will maintain an overall attendance of 90% over the half term. You will achieve a satisfactory level of progress. If you are failing to achieve expected standards this will be highlighted by the Sixth Form team & you will be given the opportunity to discuss & agree on the way forward. Failure to meet these conditions could result in the attendance and/or progress part of your bursary being reduced or stopped. Declaration If you give false or incomplete information, you may be prosecuted. I have read and understood these questions and the Privacy Notice above and declare that the information given on this form is correct and complete to the best of my knowledge and belief. I understand that: If I leave Northgate I will not be eligible to receive further payments from Northgate and may need to repay a proportion, or in exceptional cases all of the money paid to me as part of this scheme. I am not allowed to receive bursary payments at the same time as any other government training or learning allowance (this does not include Income Support). The information I have given may be shared with other agencies or organisations, as allowed by the law, for the purpose of checking my application and/or the prevention of fraud. FSM6 Signature By submitting this form and applying for a bursary you are agreeing to all of the statements and conditions above. 4

5 16 19 Bursary Application Form: Income Details (B) To be filled in by the adults who are mainly responsible for the student making the application for a bursary. If you received benefits during the last tax year (6 Apr 2016 to 5 Apr 2017) you may need to complete Benefits Income (C). B1 I am /We are the adults mainly responsible for: B2 Fill in the details below if you are the adults responsible for the student and they live with you Surname/Family Name First name Relationship to student Adult 1 Adult 2 Your income for the tax year 2016/17 This is a necessary requirement for the assessment of the student s eligibility and the size of any discretionary bursary. Evidence will need to be provided to prove income for the tax year ending in April The easiest way to tell us about household income is to use your latest Tax Credit Award Notice (TC602) as this includes all of the information required. This will record your total income. B3 I am including form TC602 Yes No Total income recorded on the form If you answered yes to question B3 go to parental/adult declaration B6. B4 Did you receive any state benefits during the tax year Yes No If you answered yes to question B4 complete questions B5 and B6, then section C on Benefits Income. B5 Income from employment or self employment Total earnings as an employee before tax and national insurance Value of benefits in kind from P9D or P11D form Total income from self employment Other income eg interest, dividends, property income, pension etc Total income Adult 1 Adult 2 1

6 Privacy notice The information that you provide on this form will be used to assess student eligibility for a Bursary payment. This information may be shared with other organisations for administration and statistical purposes; these could include the Education Funding Agency for England, the Department for Education and Suffolk County Council. Northgate High School and Sixth Form is registered under the Data Protection Act Declaration If you give false or incomplete information, you may be prosecuted. I/We have read and understood these questions and the Privacy Notice above and declare that the information given on this form is correct and complete to the best of my knowledge and belief. I/We understand that: I/We share responsibility for the information given with any partner named on this form. If the student leaves Northgate he/she will not be eligible to receive further payments from Northgate and may need to repay a proportion, or in exceptional cases all of the money paid to him/her as part of this scheme. The information given may be shared with other agencies or organisations, as allowed by the law, for the purpose of checking this application and/or the prevention of fraud. B6 Signature 1 B6 Signature 2 By submitting this form and applying for a bursary you are agreeing to all of the statements and conditions above. 2

7 16 19 Bursary Application Form: Benefit Income (C) Who needs to fill in this section? Any student who is receiving Income Support at the time of filling the form in and has the appropriate evidence to show this. Answer questions C1, C2 + C5. Any parent or carer who received any of the benefits below between 6 April 2016 and 5 April 2017 answer C1, C3, C4 and C5. It is not necessary to complete this form if you are sending in a Tax Credit Award Notice. Student C1 Name Surname/Family name C2 I am currently in receipt of Income Support started Adult 1 C3 Surname Benefits received during the year Income Support, Income based Jobseekers allowance, Incomerelated Employment and Support Allowance or Pension Credit Carer s Allowance Contribution based Employment and Support Allowance Contribution based Jobseekers Allowance Incapacity Benefit Whole Year Part Year From () To () Bereavement Allowance Adult 2 C4 Surname Benefits received during the year Income Support, Income based Jobseekers allowance, Incomerelated Employment and Support Allowance or Pension Credit Carer s Allowance Contribution based Employment and Support Allowance Contribution based Jobseekers Allowance Incapacity Benefit Whole Year Part Year From () To () Bereavement Allowance 3

8 Any additional information, eg changes in circumstances Northgate Sixth Form 2017/18 Privacy notice The information that you provide on this form will be used to assess student eligibility for a Bursary payment. This information may be shared with other organisations for administration and statistical purposes; these could include the Education Funding Agency for England, the Department for Education and, Suffolk County Council. Northgate High School and Sixth Form is registered under the Data Protection Act Declaration If you give false or incomplete information, you may be prosecuted. I/We have read and understood these questions and the Privacy Notice above and declare that the information given on this form is correct and complete to the best of my knowledge and belief. I/We understand that: I/We share responsibility for the information given with any partner named on this form. If the student leaves Northgate he/she will not be eligible to receive further payments from Northgate and may need to repay a proportion, or in exceptional cases all of the money paid to him/her as part of this scheme. The information given may be shared with other agencies or organisations, as allowed by the law, for the purpose of checking this application and/or the prevention of fraud. C5 Signature 1 C5 Signature 2 By submitting this form and applying for a bursary you are agreeing to all of the statements and conditions above. 4