16-18 Bursary Fund (Discretionary) Application

Transcription

1 16-18 Bursary Fund (Discretionary) Application Date of receipt: Important: please read the accompanying guidance notes before completing this form. Please use this form if you re under 19 on or before 31 August 2017 unless you re over 19 and are either continuing on a course you began aged 16-18, or you are aged and have an Educational Health are Plan. If you re currently in the care of the local authority, a care leaver, or are personally in receipt of Income Support (or Universal Credit), or Employment Support Allowance and Disability Living Allowance (or Personal Independence Payment), please use the Guaranteed Bursary Form instead. Make sure you answer all the questions and if you need to, continue on a separate sheet and attach it to this form. Your application won t be considered if you don t answer all the appropriate sections or you don t attach copies of all relevant evidence. The fund is limited and there s no automatic entitlement to an award. All award payments are subject to satisfactory attendance of over 90% whilst on the course. Applications will remain open until either the fund is spent, or the academic year ends. Section 1: personal details Your details 1. Student ID number 2. First name(s) 3. Surname 4. DD MM YY 5. Your age in years on 31 August Contact address Postcode 7. Telephone number Mobile 8. UCA If you don t yet have your UCA address please provide your personal address instead:

2 Course details 9. Course title Foundation Diploma in Art & Design Diploma in Art & Design (Epsom only) Extended Diploma in Art & Design - Year 1 Extended Diploma in Art & Design - Year 2 Access to Higher Education in Art & Design Extended Diploma in Creative Media Production & Technology - Year 1 Extended Diploma in Creative Media Production & Technology - Year 2 Extended Diploma in Fashion Business & Retail - Year 1 Production Design for Performance - Year Campus Canterbury Epsom Farnham Rochester Who do you live with? 11. Do you live alone in a shared house/flat with your parents or guardian with partner or spouse Do you have children? 12. Do you have any children who are financially dependent on you?* Yes (if so give details below) No Full name Full name Full name *If you re a parent under 20, Care to Learn can help pay for childcare costs. For further information and how to apply telephone or visit gov.uk/care-to-learn Are you a young carer?* 13. Yes No *A young carer is someone who is aged who cares for a family member or friend with an illness or disability, mental health condition or an addiction. If you re unsure whether this applies to you, contact your Specialist Adviser to check.

3 Are you estranged from your family?* 14. Yes No *Being estranged from your family means you ve not had verbal or written contact with them for a significant period of time and this is unlikely to change. Do you wish to apply for free school meals? 15. Yes No In order to qualify for free meals please tick the appropriate box and ensure you provide evidence if you or your parents meet one of the following criteria: in receipt of Income Support in receipt of Universal Credit in receipt of income based Job Seekers Allowance in receipt of income related Employment Support Allowance in receipt of support under part VI of the Immigration and Asylum Act 1999 in receipt of the guaranteed element of State Pension Credit in receipt of Child Tax Credit (provided there is no entitlement to Working Tax Credit); and have an annual gross income of less than 16,190, as assessed by HMRC; or in receipt of Working Tax Credit run-on (paid for 4 weeks after you stop qualifying for Working Tax Credit) and during the initial roll out of Universal Credit benefit Are you entitled to subsidised travel? (tick relevant box) Zip Oyster Card Kent 16+ Travel Card ( 400) Surrey Half Price Bus / Train Fare Card Stagecoach Megarider Arriva Student Saver Ticket Other (please specify): Will you be receiving a financial contribution from your parents towards your course costs? 17. Yes No Amount per week:

4 Please read carefully: what would you like financial help with? 18. Course costs, for example: materials and service charge, equipment pack etc. Please specify the amount you wish to apply for: If you re a second year ED student, please tick here if you need to buy a top up pack Please specify the amount you wish to apply for: Trip costs Please specify which trip you re going on: UK visit overseas visit Please specify the amount you wish to apply for: Travel Where are you travelling from? Where are you travelling to? Method of transport: Bus Train Other (please specify) Cost of ticket: per day per week per month per term per year Please specify the amount you wish to apply for: Accommodation costs (Full-time students only. Accommodation costs can only be paid directly to the landlord.) Where will you be living? Halls of residence Other (please specify) Cost of accommodation: per week per month per year Your bank account details Any award you receive towards course costs and trips will be processed directly on your behalf through the UCA online store, therefore please don t make any payments towards these unless advised to do so. Any remaining award balance will be paid directly into the bank account you specify below which should be your own account wherever possible. As part of the assessment process you re required to provide 3 months of recent bank statements for all accounts held in your name including savings accounts. Statements for parents/guardians are not usually required. Name of bank or building society Name(s) of account holder(s) Account number Sort code - -

5 Section 2: to be completed by the adult(s) who is/are responsible for the student, or students who are considered as independent Who lives in your household? 19. Please include all adults here children should be included under point 24 on page 6. I am / we are the adult(s) responsible for the student applying for the Bursary Fund Name Name Relationship to student Relationship to student Income from benefits 20. Do you or anyone else receive any of the following? Income Support Income based Job Seekers Allowance Income related Employment and Support Allowance Support under part IV of the Immigration and Asylum Act 1999 The guaranteed element of the State Pension Credit Child Tax Credit (provided there is no entitlement to Working Tax Credit) and have an annual gross income of less than 16,190, as assessed by HMRC. Universal Credit If you re in receipt of any of the above benefits, please go directly to section 3. Household income from earnings/pension/other benefits not listed above 21. Please complete for adults in the household who are employed/self-employed or in receipt of a pension: Name of earner (1) Annual gross income Name of employer Name of earner (2) Annual gross income Name of employer

6 22. Do you or anyone else receive any of the following benefits? Job Seekers Allowance (contribution based) Incapacity Benefit (or Personal Independence Payment) Employment Support Allowance (Contribution Based) Housing Benefit Working Tax Credit Child Tax Credit (where there is a gross income of more than 16,190 as assessed by HMRC) Other benefits (please specify) Other sources of household income 23. Do you or anyone else in the household receive any other sources of income, for example savings, investments, rental income or child support payments? Yes (please give details below) No Type of income per week per month per year Type of income per week per month per year Type of income per week per month per year Other dependant children in the household (excluding the student) 24. Please list other dependant children who are under 16, or aged 16 to 18 and in full-time education: Name Name Name

7 Section 3: additional information Please complete if there is any additional information you d like us to take into consideration: If you re applying for help with accommodation costs, please ensure you ve read the relevant information on the guidance sheet and policy and that you meet the criteria residential bursaries will not be awarded where a student could attend an institution closer to home or where daily travelling times are reasonable. Please state clearly your reasons for applying for help with accommodation costs:

8 Section 4: declarations I declare that the information 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 University. I further understand that I will be required to undertake to repay any grants obtained by me as a result. I understand that where I have applied for assistance with up front course costs and have not met the cost myself at the date the award is agreed, then any award for these will be paid directly to the University. I also understand that if I withdraw from my course I may be asked to repay some or all of my bursary award. Please tick if you give consent for any information regarding your application to be shared with your parent/guardian in line with the Data Protection Act and please give their address below: Parent/guardian address: Signature of student Signature of parent/guardian (where student aged under 18) Date Date Confidentiality Applications are seen only by Specialist Advisers, Gateway Advisers and if required, by the Learner Support Funds appeals panel. It may be necessary for additional information to be sought from other university staff in order for an award decision to be reached. Data Protection Act 1998 The University for the Creative Arts is a Data Controller under the Data Protection Act. The data requested in this form is covered by the notification provided by the University required by the Information Commissioner. Personal data will be used solely within Library and Student Services and the Finance Department and processed in accordance with the UCA Data Protection Policy, and in this instance, specifically for statistical purposes and electronic record keeping. The data will not be passed to any other third party without your consent, excepting when the University is required to do so by law.

9 Section 5: checklist (this section must be completed) Please tick the boxes to indicate where you have provided evidence and ensure that copies, not originals, are provided as documents cannot be returned. Please ensure you have provided all compulsory evidence and any other evidence as applicable as your application cannot be considered without it. Evidence of income (compulsory) This should relate to the year ended April 2017 or April 2016 if submitting a tax return. All benefit/tax credit income (Full Tax Credit Award Notice all pages for / Housing Benefit letter/jsa letter/esa letter/income Support letter, etc.) Earnings/pension income (P60 for tax year ending April 2017/certified accounts for ) Other sources of income (savings and investment interest statements/maintenance payments) Bank statements (compulsory) Most recent 3 months bank statements for all accounts held in your name including savings accounts. Statements for parents/guardians are not usually required. Evidence of costs (if applicable) Travel (bus/train pass) Accommodation (rental agreement) Dependents (child benefit letter/birth certificate) Other evidence required (if applicable) Evidence of carer status (for example, evidence of Carer s Allowance or letter from GP, teacher, voluntary organisation) Evidence of estrangement (for example, letter from GP, teacher, social worker) Any other evidence (please state what has been enclosed) Please return this form and your evidence to fefunds@uca.ac.uk, to the Gateway in the Library or to your campus Specialist Adviser.

10 For office use only (don t complete this page) Initial review Student name Priority group: Yes No Supporting documents received Date entered on CWC Student ID no. Application form complete Eligibility criteria verified Initials Date sent for secondary review Award decision No award made Decision made by Date decision made Award type: Equipment Pack Local Visits Trip Travel Childcare Accommodation Free meals Other Date entered on CWC Initials Notes/payment information