Application for a NHS Bursary: Academic Year 2006/07

Transcription

1 Application for a NHS Bursary: Academic Year 2006/07 Complete and return to: NHS Student Bursaries Hesketh House Broadway Fleetwood FY7 8SS Office Hours: Mon - Thurs 8.30am pm and Fri 8.30am pm PART A - YOU MUST ANSWER ALL THE QUESTIONS IN PART A OF THE FORM 1. Personal Details - to be completed by all applicants Surname Other names Title (please tick) Mr Mrs Miss Ms Other Date of birth DD / MM / YYYY Enclose a copy of your birth certificate or passport. The form will be sent back to you if you fail to do this. Permanent address Postcode address Telephone number National Insurance No. Status - please tick a box Single Married / Civil Please give date / / send a copy of your Marriage Certificate Partnership or Civil Partnership Certificate Widowed Please give date / / Divorced Please give date / / send a copy of your Divorce Decree Living with a partner Please give date / / Separated Please give date / / send a copy of your legal separation If married please give previous surname document or an explanatory note Are you disabled or do you have special needs? No Yes we will send you information about the (Please tick) Disabled Students Allowance Are you currently in care or were you in care for 3 months No Yes we will send you information about the continuously on or after your 16 th birthday? (Please tick) Care Leavers Allowance PSM1 (NEW_MED)

2 1. Personal Details (continued) - to be completed by all applicants Ethnic Origin (please tick) White - British Black - Other Asian - Other White - Irish Asian - Indian White/Black Caribbean White - Other Asian - Pakistani White/Black African Black - Caribbean Asian - Bangladeshi White and Asian Black - African Asian - Chinese Other mixed The information on your ethnic origin is gathered for statistical purposes only and is NOT used in the determination of any bursary awarded. 2. Personal Eligibility - to be completed by all applicants, regardless of nationality To be eligible for a NHS Bursary, all students regardless of nationality, must meet certain UK residence rules. In order for us to determine your eligibility could you please answer the following questions? Nationality Please provide a copy of your Birth Certificate, Passport or Certificate of Naturalisation. Country of Residence - Please give below details of where you have lived for the whole of the 3 years preceding the first academic year of your course. Country Reason From To If you are a non UK EU National and have resided in the UK for this period, please provide supporting documentation i.e. Council Tax bill, utility bill, rental/mortgage agreements etc. Employment History for this period - If you have been employed in the United Kingdom (UK) please give details below and provide P60s for this period. Full or Part Name of employer Job title time From To Educational History - If you have attended a course in further or higher education in the UK since leaving school please give details below. Full or Part Name of College Name of Course time From To 2.

3 2. Personal Eligibility (continued) - to be completed by all applicants Please complete this section if you are not a British citizen, or if you are a British citizen born outside the UK and Islands, and send supporting documentation of your immigration status, e.g. we require a full copy of your passport, your UK Residence Permit, if applicable and a letter from the Immigration and Nationality Directorate (IND) of the Home Office confirming your immigration status. If you are from the European Economic Area and have taken up employment in the UK, or are actively seeking employment, please provide documentary evidence of both your latest P60 and your most recent payslip, or if you are unemployed, a current letter from your Job Centre Plus, confirming your status. Date of arrival in the United Kingdom / / Reason for coming to the United Kingdom Immigration Status of Student - (please tick) Asylum Seeker Recognised as a Refugee Student Visa Granted exceptional leave Granted indefinite leave to Granted limited leave to to enter or remain in the UK enter or remain in the UK enter or remain in the UK Granted Humanitarian Protection Granted Discretionary Leave Granted a Right of Abode leave to enter or remain in the UK to enter or remain in the UK in the UK EEA or Swiss National EU National Other - please specify below If you are not a British citizen and your residence in the UK is because you are accompanying your parents, spouse or civil partner please give details of their immigration status below, and send supporting documentation. We require a full copy of their passport, their UK Residence Permits, if applicable and a letter from the Immigration and Nationality Directorate (IND) of the Home Office confirming their immigration status. If you are from the European Economic Area and your parents, spouse or civil partner have taken up employment in the UK, or are actively seeking employment, please provide documentary evidence of both their latest P60 and most recent payslip, or if they are unemployed, a current letter from the Job Centre Plus, confirming their status. Name of parent, spouse or civil partner Date of arrival in the United Kingdom / / Do you reside in the UK with your parents, spouse or civil partner - (please tick) Yes No Immigration status of parent, spouse or civil partner - (please tick) Asylum Seeker Recognised as a Refugee Student Visa Granted exceptional leave Granted indefinite leave to Granted limited leave to to enter or remain in the UK enter or remain in the UK enter or remain in the UK Granted Humanitarian Protection Granted Discretionary Leave Granted a Right of Abode leave to enter or remain in the UK to enter or remain in the UK in the UK EEA or Swiss National EU National Other - please specify below 3.

4 2. Personal Eligibility (continued) - to be completed by all applicants Please complete the section below if you have not been a resident in the United Kingdom for the whole of the three years preceeding the first academic year of your course because of temporary absence due to temporary employment abroard of yourself, parents, spouse or civil partner. We will also require supporting documentary evidence from the employer. Name of person in temporary employment abroad If not yourself, what is their relationship to you? The nature of the work The period(s) spent working abroad Country From To The nature of the contract. Please provide as much information as possible including: The period of the contract(s) Whether the contract includes liability for UK tax Whether the contract is renewable Whether the contract conveys an automatic right to return to the UK Please enclose a copy of the employment contract. Have you maintained a home in the UK? Please tick Yes No Please give details of any time spent in the UK Reason From To during the period abroad. Further information: Please use this space to give any other relevant information concerning you, or your parents, spouse or civil partner s employment abroad. 4.

5 3. Course and College details - to be completed by all applicants Please complete this section to give details of your course. Name of Course Please tick the boxes that apply to you Qualification MBCHB MBBS BDS Other - please specify Type of Course Full Time Part Time Other - please specify Length of Course 4 years 5 years 6 years Other - please specify Start date of Course Month Year Start date of Academic Year 2006/07 Month Year Study year in Academic Year 4 Year 5 Year 6 Other - please specify Year 2006/07 Year of course in Academic Year 4 Year 5 Year 6 Other - please specify Year 2006/07 Please give below details of the university / college you will be attending in Academic Year 2006/07. In order to assess your Bursary entitlement we need to know where you will be living during term time. If you tick the Not Known box your Bursary will be assessed at the parental home rate until you advise us otherwise and return Form PSM9 giving details of your term time address. Where will you be living during term-time? Please tick Your parent s Name of University / College home Other Not Known 4. Details of Sponsorship or Secondment - to be completed by all applicants We need to know if you will receive sponsorship from your employer during the academic year, or attend the course on secondment terms, i.e. continue to receive a salary. In most cases where students are sponsored or seconded, no Bursary is payable. Please tick the boxes that apply to you then answer the questions below: Will you receive sponsorship from your employer? Yes No Not Known Will you attend the course on secondment terms? Yes No Not Known Please tell us the amount of money you expect to receive in the academic year 1 September 2006 to 31 August 2007 Name and address of the employer providing sponsorship or secondment terms. 5.

6 5. Student Award Status - to be completed by all applicants aged under 25 on 01/09/06 In order to determine whether your award is to be means-tested on your parent s or, if applicable, on your spouse, civil partner or partner s income, we need to determine your award status, i.e. whether you are dependent on your parent s or independent. You will be classified as independent if you satisfy any of the following four criteria. As such your award will be assessed on your own resources and, if applicable, on those of your spouse, civil partner or partner. If you DO NOT satisfy any of the criteria you will be classified as a dependent student and your parent s should complete PART B of the application form. 1. Are you, or will you be, married or Yes Send a copy of your Marriage No Go to 2 in a Civil Partnership on 01/09/06? Certificate or Civil Partnership Certificate Go to Section 6 2. Are both your parents deceased? Yes Send a copy of your parents Death No Go to 3 Certificates. Go to Section 6 3. Are you irreconcilably estranged Yes Please give details below. We may need No Go to 4 from your parents? to write to you separately about this Go to Section 6 Details of estrangement: 4. Will you have supported yourself Yes Please complete Sections 4A, 4B & 4C No Go to financially for a total of 36 months and enclose evidence of your employment Section 6 before 01/09/06? 4A. Employment History - please give details of employment since leaving school. You must send proof, e.g. copies of P60s, wage slips or a letter from your employer(s). Full or Part Name of Employer Job Title time From To 4B. Educational History - please give details of any courses you have attended since leaving school. Full or Part Name of College Name of Course time From To 4C. Other information - if you have been in receipt of benefits e.g. Job Seekers Allowance, Sickness / Incapacity Benefit etc., on a Government Training Scheme or you were unable to work because you had to care for a young person, please give details below. You must send proof to support your claim. Details From To 6.

7 6. Means-Testing: Student s Own Resources - to be completed by all applicants Please complete the section below to show your expected income and expenses in the academic year 1 September 2006 to 31 August You should exclude earnings for work done in the evenings, at weekends or during holidays whilst you are attending your course, unless you are a part-time student. Estimated income in the Academic Year 2006 / 2007 (Write Nil where there is no income) p Sponsorship / Scholarship/ Include any payments to be made for periods for which Cadetship you have leave of absence or relief from duties. Income from employer Pensions Include any income from your employer if you are to be released to attend the course or if you will be studying part-time. Include any Widows Pension, Occupational Pension or Private Pension. Bank or Building Society interest (after tax) Income from lettings or lodgings Income from Covenants Other unearned income Social Security Benefits Only include income if the payment is to be made by a divorced or separated parent whose income will not be used in assessing your award; or by any other person. Include any other unearned income, e.g. income from dividends. Include taxable benefits, e.g. Job Seekers Allowance, Incapacity Benefit. Do NOT include any disability related benefit or Child Benefit. Maintenance (before tax) Any other income not shown above Estimated Expenses in Academic Year 2006 / 2007 (Write Nil where there are no expenses) p Income Tax National Insurance Contributions Employee Pensions Contributions Personal Pension / retirement annuity payments Life insurance premiums Mortgage payments Wages for domestic help Maintenance payments Include the cost of domestic assistance resulting from the care of a member of the household with a disability or illness. Include any money you pay to an ex spouse or partner. Please send proof. 7.

8 7. Means-Testing: Spouse, Civil Partner or - to be completed by the applicant s spouse, Partner s Income and Expenses or, if applicable, their civil partner or partner To enable us to means test your award please ask your spouse, civil partner, or partner if you are aged 25 years or over on 30 September 2006 and you live with someone as if you are married, to complete this section. If your spouse, civil partner or partner chooses not to disclose their income, your Bursary will be automatically assessed at 0.00 and you will not be entitled to the reimbursement of any additional expenses whilst you are on practice placements. The NHS will however, pay any liability for a tuition fee contribution. Surname Other names Title (please tick) Mr Mrs Miss Ms Other Occupation Please tick one box Do you wish to declare your income? Yes Please give No Please sign the declaration details below at Section 13 Income from 6 April 2006 to 5 April 2007 Salary or Wages (Gross Taxable) Taxable Allowances e.g.car, fuel, private health care Income from self-employment or Company Directorship Income from land, property or furnished lettings Widow s Benefits (if taxable) State retirement pension Other pensions Bank or Building Society interest (after tax) Other unearned income (after tax) Other Social Security Benefits (if taxable) Maintenance received p 8. (Write Nil where there is no income) You must send proof, e.g. a copy of your P60, P45 or your March 2006 payslip showing totals for the year. If these are not available please ask your employer to complete form PSM60 included in the application pack Show any other income or benefits in kind such as allowances for car or fuel, private health care etc. You must send a copy of your latest P2(T) Notice of Tax Coding. Enter gross income. You must send proof such as a copy of your audited accounts. Alternatively, complete form PSM65 included in the application pack showing the figures given on your tax return, or ask your accountant to complete it. Include any widow s pension, occupational pension or private pension. Please send proof e.g. a copy of your P60. Include any other unearned income e.g. income from dividends. Include taxable benefits e.g. Job Seekers Allowance, Incapacity Benefit. You must send proof such as a letter from the Benefits Agency. Do NOT include any Disability Related Benefit that is tax free. Include any maintenance or income you receive from an ex spouse or partner. Please send proof e.g. a letter from the Child Support Agency, or copy of a Court Order.

9 7. Means-Testing: Spouse, Civil Partner or - to be completed by the applicant s spouse, Partner s Income and Expenses (continued) or, if applicable, their civil partner or partner Expenses from 6 April 2006 to 5 April 2007 (Write Nil where there are no expenses) Employee pension contributions p Personal Pension / Retirement Annuities Other loan interest (if allowed for tax purposes) Professional subscriptions and any other expenses attracting tax relief Wages for domestic help Maintenance payments Please ask your pension company to complete form PSM90 included in the application pack This is only applicable if you are self-employed. Please send a copy of your self assessment tax return. Please send a copy of your P2(T) Notice of Tax Coding 2006/2007 or a copy of your self assessment tax return. Please include the cost of domestic assistance resulting from the care of a member of your household with a disability or illness. Please send proof, e.g. a letter from the Child Support Agency, or a copy of a Court Order. Additional Information: Please use the space below to provide any additional information concerning your income and expenses in the 2005/2006 financial year. 7A. Calculation of a Spouse, Civil Partner or Partner s - to be completed by the applicant s spouse Contribution: Details of other Dependants or, if applicable, their civil partner or partner It may be possible to offset against the assessed contribution an allowance for each dependent child based on your residual income i.e. income less expenses shown in Section 7. Please show below details of any other children that will be dependent on you in the period 1 September 2006 to 31 August If you have another child(ren), who will also be attending a course in higher education and who will be in receipt of a means-tested award (normally a student loan) assessed by your Local Education Authority (LEA) it should be possible to share the assessed contribution with them. In such circumstances we will contact the LEA to agree the financial details you have provided and to agree the level of contribution to be offset against the NHS Bursary award. This agreement should have been obtained before the start of the academic year. Please note, that without agreement the full contribution will be deducted from any Bursary awarded. If applying for a means-tested Child s name D.o.B. Full-time Education? award for Academic Year Please tick 2006/07 please name LEA Yes Yes Yes Yes No No No No 9.

10 8. Dependant s Allowances: Details of Dependants - to be completed by the applicant If you wish to claim Dependant s Allowances please complete this Section giving details of any person who will be wholly or mainly financially dependent upon you during the academic year 1 September 2006 to 31 August This allowance can only be awarded if you can fully demonstrate that the dependants are wholly or mainly financially dependent upon you. You should also complete this section if you are submitting an application for Childcare Allowance This allowance is means-tested on your anticipated residual income and, if applicable, that of your spouse, civil partner or partner, in the academic year. We will use your income details provided at Section 6, along with those of your spouse or partner at Section 8A, to calculate your entitlement. To support your claim for the Dependants Allowance please include with your application the following documentation: photocopies of the birth certificates for all claimed dependants a photocopy of your marriage certificate, if you are married a photocopy of your civil partnership certificate, if you have entered into a Civil Partnership on or after 5/12/05 a photocopy of your divorce decree, if you are divorced evidence of separation if you are separated, but not yet divorced details and evidence of your income (excluding any Bursary awarded) details and evidence of your spouse, civil partner or partner s income, if you are married, in a civil partnership or live with someone as if you were married photocopies of adoption papers, if you have adopted the claimed dependant(s) photocopies of your child(rens) visa s if not born in the UK It is expected that applicants will normally only claim Dependants Allowances for dependants who reside with them. If your dependants will NOT be living with you during term-time, you will have to provide supporting documentary evidence that they remain wholly or mainly financially dependent upon you. You will not be awarded the Dependants Allowances without this proof. The supporting documentary evidence may be: photocopies of Solicitors letters supporting your claim photocopies of Court Orders making instructions that you are required to provide financial support photocopies of current Child Support Agency (CSA) agreements. Please remember that if your ex-spouse, civil partner or partner is wholly or mainly financially responsible for the dependent children you will not receive dependants allowances regardless of any judgements made by the CSA or in a legal judgement. Details of Spouse, Civil Partner or Partner Surname Other names Date of birth / / Relationship to you Will your spouse, civil partner or partner be living with you during term time? Yes No Occupation If currently in employment, is it (Please tick) Full-time Part-time Please answer the following questions if your spouse, civil partner or partner will be undertaking a course in further or higher education in the Academic Year 2006/07 Name of College or University Name of Course Details of any funding whilst in training 10.

11 8. Dependant s Allowances: Details of Dependants (continued) - to be completed by the applicant Details of 1 st Child Surname Other names Date of birth / / Relationship to you Will the child be living with you during term-time? (Please tick) Yes No If the child has left school and is in employment what is their occupation? Please give an estimate of income, including any maintenance of If no income write Nil the child in your academic year 1 September 2006 to 31 August Please answer the following questions if the child has left school and will be undertaking a course in further or higher education in the Academic Year 2006/07 Name of College / University Name of Course Details of any funding whilst in training If the child has left school and is unemployed please give details of any benefits they receive: Details of 2 nd Child Surname Other names Date of birth / / Relationship to you Will the child be living with you during term-time? (Please tick) Yes No If the child has left school and is in employment what is their occupation? Please give an estimate of income, including any maintenance of If no income write Nil the child in your academic year 1 September 2006 to 31 August Please answer the following questions if the child has left school and will be undertaking a course in further or higher education in the Academic Year 2006/07 Name of College / University Name of Course Details of any funding whilst in training If the child has left school and is unemployed please give details of any benefits they receive: 11.

12 8. Dependant s Allowances: Details of Dependants (continued) - to be completed by the applicant Details of 3 rd Child Surname Other names Date of birth / / Relationship to you Will the child be living with you during term-time? (Please tick) Yes No If the child has left school and is in employment what is their occupation? Please give an estimate of income, including any maintenance of If no income write Nil the child in your academic year 1 September 2006 to 31 August Please answer the following questions if the child has left school and will be undertaking a course in further or higher education in the Academic Year 2006/07 Name of College / University Name of Course Details of any funding whilst in training If the child has left school and is unemployed please give details of any benefits they receive: Details of 4 th Child Surname Other names Date of birth / / Relationship to you Will the child be living with you during term-time? (Please tick) Yes No If the child has left school and is in employment what is their occupation? Please give an estimate of income, including any maintenance of If no income write Nil the child in your academic year 1 September 2006 to 31 August Please answer the following questions if the child has left school and will be undertaking a course in further or higher education in the Academic Year 2006/07 Name of College / University Name of Course Details of any funding whilst in training If the child has left school and is unemployed please give details of any benefits they receive: 12.

13 8. Dependant s Allowances: Details of Dependants (continued) - to be completed by the applicant Details of 5 th Child Surname Other names Date of birth / / Relationship to you Will the child be living with you during term-time? (Please tick) Yes No If the child has left school and is in employment what is their occupation? Please give an estimate of income, including any maintenance of If no income write Nil the child in your academic year 1 September 2006 to 31 August Please answer the following questions if the child has left school and will be undertaking a course in further or higher education in the Academic Year 2006/07 Name of College / University Name of Course Details of any funding whilst in training If the child has left school and is unemployed please give details of any benefits they receive: Details of 6 th Child Surname Other names Date of birth / / Relationship to you Will the child be living with you during term-time? (Please tick) Yes No If the child has left school and is in employment what is their occupation? Please give an estimate of income, including any maintenance of If no income write Nil the child in your academic year 1 September 2006 to 31 August Please answer the following questions if the child has left school and will be undertaking a course in further or higher education in the Academic Year 2006/07 Name of College / University Name of Course Details of any funding whilst in training If the child has left school and is unemployed please give details of any benefits they receive: 13.

14 8A. Dependant s Allowances: Income and Expenses - to be completed by the applicant s spouse, civil partner or partner Estimated income in the period 1 September 2006 to 31 August 2007 p (Write Nil where there is no income) Salary or Wages (Gross Taxable) Taxable Allowances e.g. car, fuel, private health care Income from self-employment or Company Directorship Please send a copy of your most recent payslip Show any other income or benefits in kind such as allowances for car or fuel, private health care etc. Enter gross income Income from land, property or furnished lettings Widow s Benefits (if taxable) State Retirement Pension Other Pensions Bank or Building Society interest (after tax) Other Social Security Benefits (if taxable) Include any widow s pension, occupational pension or private pension Include taxable benefits, e.g. Job Seekers Allowance, Incapacity Benefit. Please send proof such as a letter from the Benefits Agency. Do NOT include any disability related benefits which are tax free. Maintenance Any other income not shown above Estimated Expenses in the period 1 September 2006 to 31 August 2007 p (Write Nil where there are no expenses) Income Tax National Insurance Contributions Employee Pension Contributions Personal Pension / Retirement Annuity payments Life insurance premiums Mortgage payments Wages for domestic help Maintenance payments Include the cost of domestic assistance resulting from the care of a member of the household with a disability or illness. Please send proof, e.g. a letter from the Child Support Agency, or a copy of a Court Order. 14.

15 9. Single Parent Addition - to be completed by applicants who are lone parents If you are a lone parent you may be entitled to additional financial help, known as the Single Parent Addition. Please sign the required legal undertaking below. If you are awarded the Single Parent Addition you will NOT be entitled to the Older Students Allowance but in order for us to calculate your full entitlement the Declaration MUST be signed by all single parents, including those who qualify for the Older Students Allowance instead. I confirm that I am supporting my child(ren) and that I will not be living with a spouse, or any person as a spouse during this academic year 1 September 2005 to 31 August Should my circumstances change during this period I understand that it is my responsibility to inform you immediately. Signature of student Date / / 10. Two Homes Grant - to be completed by applicants with dependants, if applicable If you have to maintain a home for yourself and one or more dependants, other than the home you live in when you attend the course, you may be eligible for an extra allowance called the Two Homes Grant. The grant is payable only if you are entitled to dependant s allowances. To claim the Two Homes Grant please complete the following: Where will your spouse or children be living during term-time? Please tick With you? In a separate home maintained by you? Other? - please give details below Please provide below details of your dual accommodation costs i.e. the costs you will incur in maintaining your permanent and term-time addresses: 15.

16 11. Childcare Allowance Notes If it is your intention to use registered or approved childcare in Academic Year 2006/07, i.e. during the period 1 September 2006 to 31 August 2007, please read carefully the Question and Answer sheet Applying for the NHS Bursary Childcare Allowance: What you need to know and complete the Childcare Allowance application form included in your pack. In particular please note: that your child minder or childcare provider: must be registered by the Office for Standards in Education (Ofsted), or be approved by a specially accredited organisations Quality Assurance Scheme, or be registered under the Government s Sure Start Childcare Approval Scheme, and that you cannot claim the allowance for any period for a child: for whom you receive the childcare element of the Working Tax Credit, or for whom you receive free early years education from your Local Authority You should also complete Sections 8 and 8A of this form. 12. Details of Bank or Building Society - to be completed by all applicants Please give details of the bank or building society that you want your Bursary to be paid into. It is your responsibility to ensure that your Bank or Building Society is able to accept Bank Automated Credit payments (BACS). Please complete this section carefully and print the details clearly. To help us validate your bank account details it would be helpful if you could enclose a paying-in slip or a photocopy of a recent statement. If you do not yet have details of the account into which you want your Bursary to be paid, please leave this section blank. When your details are known please complete form PSM10, sent with the application pack. Name of Bank or Building Society Address of Bank or Building Society Please print the details clearly below Name of Account Holder(s) Sort code Account number Building Society Number (if applicable) 16.

17 13. Declaration - to be signed and dated by all applicants and their spouse, civil partner or partner (if applicable) Please note that failure to sign the declaration by you, and if appropriate by your spouse or partner, will result in the application form being returned. I declare that the information in this application is to the best of my knowledge correct and complete, and I undertake to inform the NHS Business Services Authority Student Bursaries of any alterations to the details provided. I undertake to attend regularly the course for which my award is given and to inform the NHS Business Services Authority Student Bursaries of any alterations in the particulars given and supply any additional information that may be required. I understand that if I fail to comply with a request for information, or I provide information that I know to be false, the payment of Bursary, allowances and/or tuition fee contributions may be terminated or withheld. I understand that it is my responsibility to inform the NHS Business Services Authority Student Bursaries should I leave training. On interruption or cessation of training, or if any additional information is received which affects the level of entitlement to a Bursary, allowances or tuition fee contributions, my award will be reassessed and the NHS Business Services Authority Student Bursaries will inform me in writing of my revised entitlement (the notification). I undertake to repay any monies received by me in excess of my revised entitlement within 30 days of notification (the due date). Should I fail to make full repayment of any amount due or agree an acceptable repayment plan with the NHS Business Services Authority Student Bursaries by the due date, the debt may be passed to a debt collection agency. I agree that I will be charged for any additional recovery costs at the rate of 7% which will be added to the balance outstanding on referral. I consent to the NHS Business Services Authority Student Bursaries using the data supplied by me on this form in data-matching or data-sharing activity connected with the prevention and detection of fraud. Signature of applicant Date / / I declare that the information included in this application is to the best of my knowledge correct and complete and I undertake to inform the NHS Business Services Authority Student Bursaries of any alteration to the details provided. Signature of applicant s spouse, civil partner or partner Date / / Important Notes The NHS Business Services Authority Student Bursaries is registered under the Data Protection Act. Because we have a duty to protect the public funds we administer, you agree that we may use the information you provide on this form (and share it with other bodies who administer public funds and other approved third parties who are also registered under the Data Protection Act): to prevent and detect fraud to trace and contact students who fail to inform us of their new address; to approach students and the next of kin of students (in case of students under the age of 18) who have outstanding balances due to the NHS Business Services Authority Student Bursaries and collect overdue repayments via approved third parties. NB: The NHS Business Services Authority Student Bursaries will not be held responsible for the loss of any original documents 17.

18 14. Additional Information Please use the space below to give any additional information you feel may be useful to us. 18.

19 PART B - To be completed by the Parent(s) of a Dependent Applicant 1. Parent s Details Title (please tick) Mr Mrs Miss Ms Dr Surname Other names Address Telephone number Occupation Postcode What is your relationship to the student? Father Mother Other (give details) If you choose not to disclose your income the students Bursary will be automatically assessed at 0.00 and they will not be entitled to the reimbursement of any additional expenses whilst on practice placements. The NHS will, however, pay any liability for a tuition fee contribution. Do you wish to declare your income? Yes please complete No please sign the declaration (Tick all boxes that apply to you) Sections 2,3 & 4 at Section 4 Will you show the income and expenses for yourself and the student s other parent? Yes No If NO please state why Give date of separation, divorce or widowhood, if applicable / / Please provide proof if not supplied previously 2. Calculation of Parental Contribution - Details of other Dependent Children It may be possible to offset an allowance for each dependent child against the assessed contribution based on your residual income i.e. income less expenses shown in Section 3. Do NOT include the child you are making this application for. Please show details of all your other dependent children in the period 1 September 2006 to 31 August 2007 below. If you have another child(ren), who will be attending a course in higher education and who will be in receipt of a means-tested award (normally a student loan) assessed by your Local Education Authority (LEA) it should be possible to share the assessed contribution with them. In such circumstances we will contact the LEA to agree the financial details you have provided and to agree the level of contribution to be offset against the NHS Bursary award. This agreement should have been obtained before the start of the academic year. Please note that without agreement the full contribution will be deducted from any Bursary awarded. Child s name D.o.B Full-time (Please tick) If applying for a means-tested award for Education? Academic Year 2006/07, name the LEA Yes Yes Yes Yes No No No No 19.

20 3. Means-Testing - Parent s Income and Expenses - to be completed by the applicant s parent(s) Income from 6 April 2005 to 5 April 2006 (Write NIL where there is no income) Father Mother p p Salary or Wages You must send proof e.g. a copy of (Gross taxable) your P60, P45 or your March 2006 payslip showing totals for the year. If these are not available please ask your employer to complete form PSM60 included in the application pack. Taxable Allowances e.g. car, fuel, private health care Income from self-employment or Company Directorship Show any other income or benefits in kind such as allowances for car or fuel, private health care etc. You must send a copy of your latest P2(T) Notice of Tax Coding. Enter gross income. You must send proof such as a copy of your audited accounts. Alternatively, complete form PSM65 included in the application pack showing the figures given on your tax return, or ask your accountant to complete it. Income from land, property or furnished lettings Widow s Benefits (if taxable) State Retirement Pension Other Pensions Include any widow s pension, occupational pension or private pension. Please send proof e.g. a copy of your P60. Bank or Building Society Interest (after tax) Other unearned income (after tax) Other Social Security Benefits (if taxable) Maintenance received Include any other unearned income, e.g. income from dividends Include taxable benefits e.g. Job Seekers Allowances, Incapacity Benefit. You must send proof such as a letter from the Benefits Agency. Do NOT include any disability related benefit which is tax free. Include any maintenance or income you receive from an ex-spouse or partner. Please send proof e.g. a letter from the Child Support Agency, or a copy of a Court Order. Additional information: 20.

21 3. Means-Testing - Parent s Income and Expenses (continued) - to be completed by the applicant s parent(s) Expenses from 6 April 2005 to 5 April 2006 (Write Nil where there are no expenses) Father Mother p p Employee pension contributions Personal Pension / Retirement Annuities Other loan interest (allowed for tax purposes) Professional subscriptions and any other expenses attracting tax relief Wages for domestic help Maintenance payments Please ask your pension company to complete form PSM90, sent with the application pack. This is only applicable if you are self-employed. Please send a copy of your Self-Assessment Tax Return. Please send a copy of your P2(T) latest Notice of Tax Coding or a copy of your Self-Assessment tax return. Please include the cost of domestic assistance resulting from the care of a member of your household with a disability or illness. Please send proof e.g. a letter from the Child Support Agency, or a copy of a Court Order. 4. Parent s Declaration - to be signed and dated by the applicant s parent Please note that failure to sign the declaration by the parent will result in the application form being returned. I declare that the information included in this application is to the best of my knowledge correct and complete, and I undertake to inform the NHS Business Services Authority Student Bursaries of any alteration to the details provided. I understand that if I fail to comply with a request for information, or I provide information which I know to be false, the payment of the Bursary, allowances or tuition fee contributions may be terminated or withheld. I consent to the NHS Business Services Authority Student Bursaries using the data supplied by me on this form in data-matching or data-sharing activity connected with the prevention and detection of fraud. Signature of parent Date / / Important Notes: The NHS Business Services Authority Student Bursaries is registered under the Data Protection Act. Because we have a duty to protect the public funds we administer, you agree that we may use the information you provide on this form (and share it with other bodies who administer public funds and other approved third parties who are also registered under the Data Protection Act): to prevent and detect fraud to trace and contact students who fail to inform us of their new address; to approach students and the next of kin of students (in case of students under the age of 18) who have outstanding balances due to the NHS Business Services Authority Student Bursaries and collect overdue repayments via approved third parties. 21.

22 When posting the application please ensure you have: Completed and signed all the relevant sections of the application form Enclosed photocopies of all relevant supporting documents. We cannot be held responsible for the loss of original documents. As the application form and enclosures may weigh more than the minimum postage please ensure that the package is weighed and the correct postage paid. For office use only Total net income of dependants Dependants Allowances Spouse / 1 st Child Less total disregard Balance of income Child Child Child Child Child Child TOTAL Less balance of income Net Dependants Allowances Payable Validated Checked by Date / / by Date / / Additional Notes 22.