Council House, Priory Road, Dudley, West Midlands, DY1 1HF
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Early Years Pupil Premium Application

Use this form to apply for theEarly Years Pupil Premium (EYPP)for 3 and 4year olds.

We will use the information you provide to check your eligibility for EYPP, and contact other sources as allowed by law to verify your eligibility.

Do you agree to our use of the information you provide in this way?

(Please note will be unableto process your application if you do not agree for us use your information in this way)

Criteria:

Please indicate which of the following apply to you or your child:

Income Support
Jobseekers Allowance (income based)
Employment & Support Allowance (income related)
Universal Credit
State Pension Credit (guaranteed element)
Child Tax Credit (household income no more than £16,190)
Working Tax Credit 4 week run on ( the payment you get when you stop qualifying for Working Tax Credit)
Support under Part VI of the Immigration & Asylum Act 1999
Disability Living Allowance (Child)
Child left care through special guardianship, adoption or residence order
Looked after Child (in the care of the Local Authority)

Data Protection Statement

The information you provide on this form is subject to the provision of the Data Protection Act 1998.

Your information will be processed in accordance with Data Protection legal requirements. Please see the Council's Privacy Statement and Charter and will be used by DMBC for the purposes of processing your application, monitoring and evaluating the service and measuring outcomes. Data may be shared with relevant departments within Dudley MBC, relevantgovernment departments as necessary, and Childcare Providers and Schools.

Please refer to our Privacy & Disclaimer Statement below for our Information Charter and general information on our approach to security, confidentiality, data collection, etc. Further data protection information can be obtained from the Information Commissioner's website at

Applicant details:

Please provide details of the parent in receipt of benefits:

Please complete mandatory* fields below, failure to do so will delay your application.

Title
First name*
Last name*
Date of Birth*
National Insurance number*
Contact number *
E-mail address
Address & postcode

About your child/children:

Please give details for each child:

Child 1:

Childs first name*
Childs last name *
Gender of child (male/female)
Childs date of birth (dd/mm/yyyy)
Childs relationship to you
Is this child already attending childcare (Yes /No) / If yes – please give details below
School/childcare provider*
Hours received
Additional school/childcare provider
Additional hours received

Child 2:

Childs first name*
Childs last name *
Gender of child (male/female)
Childs date of birth (dd/mm/yyyy)
Childs relationship to you
Is this child already attending childcare (Yes /No) / If yes – please give details below
School/childcare provider*
Hours received
Additional school/childcare provider
Additional hours received

Child 3:

Childs first name*
Childs last name *
Gender of child (male/female)
Childs date of birth (dd/mm/yyyy)
Childs relationship to you
Is this child already attending childcare (Yes /No) / If yes – please give details below
School/childcare provider*
Hours received
Additional school/childcare provider
Additional hours received

Declaration

I declare that the information I have given on this form is correct and complete. I understand that if I give information that isincorrect or incomplete, you may take action against me.

I confirm the above declaration *☐

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