Sir George Monoux College
Bursary and Free College Meal Application Form
Academic Year 2016/2017
Section 1: Learner Details – to be completed by the applicant – (student)
Please complete in capital letters and in black pen
Student ID Number: …………..…………………………………………………………..First Name: …………………………………………………………………………………
Last Name: …………………………………………………………………………………
Date of Birth: …………………………………Age on the 31/08/2016………………....
For Official Use Only
Description / Amount
Working Tax Credit / £
Child Tax Credit / £
Income (work) / £
Other / £
Other / £
TOTAL / £
Bursary FCM
Approved:
Declined:
Pending:
Comments:
Initial Assessment Date………………….. Final Assessment Date………………………
Staff Signature…………………………………. Staff Signature………………………………….
Section 2: Residency – please circle the residency criteria that applies to you - to be completed by the applicant (student)
Category / CriteriaA / I am a British Citizen and have lived in the UK for at least three years prior to the start of my learning programme.
B / I have ‘settled status’* and have been ordinarily resident in the UK for at least three years prior to the start of my learning programme.
*’Settled Status’ means having either indefinite leave to enter or remain or having the right of abode in the UK.
C / I am a national of an EU Country or child of an EU National and have been ordinarily resident in the European Economic Area (EEA) or Switzerland for at least three years prior to the start of my learning programme.
D / I am the child of an EEA migrant worker or the child of a Swiss national or the child of a Turkish Migrant Worker and have been ordinarily resident in the European Economic Area (EEA) or Switzerland for at least three years prior to the start of my learning programme.
E / I am the child of a refugee who has been granted Humanitarian protection, or have temporary EU protection.
Section 3: Vulnerable Groups- to be completed by the applicant (student)
Please tick the group which applies to you, however, if you do not fall into any of the groups listed, please tick the box indicated below none of the above.
I am in the care of my Local Authority
(You must enclose a letter from your Local Authority to confirm your circumstances)
I am currently receiving Universal Credit/Income Support
(You must enclose a letter from the Department of Work and Pensions as evidence)
I am a Care Leaver
(You must enclose a letter from your Local Authority to confirm your circumstances)
I am currently receiving Employment Support Allowance/Universal Creditand Disability Living Allowance
(You must enclose a letter from the Department of Work and Pensions as evidence)
I am currently receivingEmployment Support Allowance/Universal Credit and Personal Independence Payment
(You must enclose a letter from the Department of Work and Pensions as evidence
If none of the above categories apply to you, please tick this box.
Section 4: Guidance for Bursary and FCM (To be completed by Parent/carer)
This next section of the bursary and Free College Meal application needs to be completed by your parent/carer. However, if you (the student) are living independently YOU will need to complete section 5.
In order to be eligible for theBURSARY your total household income must be less than £23,000. (This can be made up from full/part time work, benefits and or pensions.) It includes all income to the household from any persons residing at the stated address, all evidence must be provided.
In order to be eligible for FREE COLLEGE MEALS you must be in receipt of at least one of the benefits below and have a household gross income of no more than £16,190.It includes all income to the household from any persons residing at the stated address, all evidence must be provided.
Please note “Child Benefit” is not an income based benefit, therefore, receipt of it does not prove income nor can it be used as proof to determine eligibility for the 16-19 Bursary Fund.
Section 5:Total Household Incometo be completed by the Adult(s) responsible for the Young Person(you will need to provide photocopies of current and relevant proof of receipt of benefits/income)
Adult 1Surname: …………………………………
First Name: ………………………………
Relationship to young person:
…………………………………………….
Please tick the box which applies to you…
I currently receive: / Adult 2
Surname: ……………………………………
First Name: …………………………………
Relationship to young people:
………………………………………………
Please tick the box which applies to you…
I currently receive:
Universal Credit
(You will need to provide a current Letter dated from April 2016onwards from the Department of Work and Pensions) / Universal Credit
(You will need to provide a current Letter dated from April 2016 onwards from the Department of Work and Pensions)
Employment Support Allowance (ESA)
(You will need to provide a current Letter dated from April 2016onwards from the Department of Work and Pensions) / Employment Support Allowance (ESA)
(You will need to provide a current Letter dated from April 2016 onwards from the Department of Work and Pensions)
Income Support
(You will need to provide a current Letter dated from April 2016 onwards from the Department of Work and Pensions) / Income Support
(You will need to provide a current Letter dated from April 2016 onwards from the Department of Work and Pensions)
Jobseeker’s Allowance (JSA)
(You will need to provide a current Letter dated from April 2016onwards from the Department of Work and Pensions) / Jobseeker’s Allowance (JSA)
(You will need to provide a current Letter dated from April 2016 onwards from the Department of Work and Pensions)
Pension Credit (Guarantee Credit)
(You will need to provide a current Letter dated from April 2016 onwards from the Department of Work and Pensions) / Pension Credit (Guarantee Credit)
(You will need to provide a current Letter dated from April 2016onwards from the Department of Work and Pensions)
Employment/Self Employment
( Most recent P60/Accountant statement/Employment contract post April 2016) / Employment/Self Employment
(Most recent P60/Accountant statement/Employment contract Post April 2016)
Working Tax Credit/Child Tax Credit Award(TC602)
(Please provide your most recent Tax Credit Award. April 2016 to April 2017. Please note we require all pages) / Working Tax Credit/Child Tax Credit Award(TC602)
(Please provide your most recent Tax Credit Award. April 2016 to April 2017. Please note we require all pages)
Section 6: Student Declaration–To be signed by the applicant (student)
- I declare that all information given on this form is true to the best of my knowledge and belief
- I agree to supply any additional information that may be required
- I have read and understand the “Bursary and Free College Meal Guidance Handbook”on the college website.
- I have not applied for a Bursary or Free College Meal at any other college or institution
- I understand that this Bursary is for Educational purposes only and that I must achieve 90% attendance at all timetabled classes in each term or payments will be withdrawn or withheld.
Signature: ………………………………………………… Date: ………………………
Print Name: ……………………………………………....
Section 7: Parent/Carer Declaration– This declaration is to be signed by the Parent(s)/Guardian/Carer of the applicant.
- I declare that all information given on this form and associated documents are true to the best of my knowledge and belief.
- I have read and understand the “Bursary and Free College Meal Guidance Handbook”on the college website.
- I understand that this Bursary is for Educational purposes only and that my son/daughter must achieve 90% attendance at all timetabled classes in each term or payments will be withdrawn or withheld.
- I understand that Sir George Monoux College may make any necessary enquiries to verify my circumstances and I agree to supply any additional information that may be required.
- I accept that public funds must be handled and managed appropriately and therefore give my permission for the information provided to be used to prevent and detect fraud.
- I understand that if I falsify any of the information recorded on this application, I am liable and if found out will be made to repay the Bursary and/or Free College Meal Award in full.
Signature 1: …………………………………………………… Date: ………………………
Print Name: ……………………………………………………
Signature 2: …………………………………………………… Date: ………………………
Print Name: ……………………………………………………
Please complete this sheet for our finance office. In order for payments to be processed you will need to complete the form accurately and in full.
Section 8: Your Bank or Building Society Account Details – to be completed by the applicant (student)
(To receive payments, you must ensure you have a bank account in your own name as it appears on your passport. If not, you will need to open one before you can complete this application). Please attach a photocopy of a recent bank statement as proof of your account details (please note we cannot process your application without a recent bank statement)
Surname: …………………………………………………………………………………..First name: …………………………………………………………………………………
Student I.D Number: ………………………………………………………………………
Date of Birth: …………………………………Age on the 31/08/2016:………………...
Address: …………………………………………………………………………………….
………………………………………………………………………………………………..
………………………………………… Post Code: ………………………………………
Home Telephone: ………………………………………………………………………….
Mobile Telephone: …………………………………………………………………………
Email Address: …………………………………………………………………………….
Name of Account Holder: …………………………………………………………………..
(this should be written as it appears on your card/bank statement and/or passport)
Name of Bank/Building Society: ……………………………………………………………
Branch Name: ………………………………………………………………………………..
Sort Code: ______
Account Number: ______
(Your account number can be found on your bank/building society statement. Most account numbers are 8 digits long)
Roll Number: …………………………………………………………………………………
(only for building society accounts)
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