C O N F I D E N T I A L

BURSARY FUND APPLICATION FORM FOR 2015 – 2016

The completed application form and evidence must be handed in within 4 weeks of your start date. If the application form and evidence is presented later than that date, we cannot guarantee that your application will be supported and processed in time to receive a payment in November.

Failure to provide the supporting evidence we require will result in delays in processing your application.

Learner Details
Please provide your personal details.
Student Number :
Title:
Surname:
First Name(s):
Date of Birth: //
Age: / Address:
Postcode:
Telephone:
Mobile:
Email: /
Have you been a resident in the UK for the last 3 years? YES NO
Course Details
Please provide us with as much information as you can about your course of study
Are you: / Full-time? / Part-time?(Please tick)
Course Title:
Centre of Study: (Please indicate)
Bradford / Guisborough / Leeds/ Middlesbrough / Newcastle / Newton Rigg / Scarborough /
Wakefield / York
Other / Course Start Date:
//
Duration:
1 Year
2 Year
VULNERABLE BURSARY CRITERIA
To qualify for a vulnerable bursary you must fall into one of the below categories and produce the required evidence as stated.
Are you in receipt of income support in your own name - you must attach a letter of proof / YES NO
Care leaver or currently looked after in care – you must attach a letter from the Local Authority. / YES NO
Disabled student in receipt of both Employment Support Allowance/ Universal Credit and Disability Living Allowance/ Personal Independence Payments – Evidence of benefits/ entitlement letter must be provided. / YES NO
DISCRETIONARY BURSARY CRITERIA
To qualify your household income must be below £30, 000. Please tick to indicate what type of evidence you have provided. If you cannot provide evidence then we cannot process your application.
P60 for 2014-15 / Income Support / Full Tax Credit Award
notice for 2014-15
Self-employment earnings
(official tax return 2014-15) / Other benefits/ pension
(award letter) / Wage slips for the household
(last three months)
24+ BURSARY CRITERIA
To qualify you must be in receipt of the 24+ Advance Learning Loan.
I am in receipt of the 24+ Advanced Learning Loan – and have attached a copy of a letter to confirm this. / YES NO
I am able to Provide evidence of your household incomebeing below £30,000 / YES NO
FREE MEALS
Are you applying for a free meal? YES NO
This entitlement is for targeted learners who are aged between 16-18 years on 31st August 2015. If a student turns 19 during the academic year they will remain eligible for free meals until the end of the year. In order to qualify the student or parents must be in receipt of one or more of the following benefits:-
Type of Benefit / ADULT 1 / ADULT 2 / EVIDENCE REQUIRED
Jobseekers Allowance income based / YES NO / YES NO / If you have ticked “YES” in any of these boxes you must attach a letter of proof for each benefit you receive from the Benefits Office/ Local Authority. If you are in receipt of Child Tax Credits we require a copy of your Tax Credit Award notice for 2014-15. If you do not send the supporting evidence we will not be able to process your application.
ESA – income related Employment Support Allowance / YES NO / YES NO
Income Support / YES NO / YES NO
Guarantee element of State Pension Credit / YES NO / YES NO
Child Tax Credit / YES NO / YES NO
Support under part V1 of the Immigration and Asylum Act 1999 / YES NO / YES NO
Universal Credit / YES NO / YES NO
Working Tax Credit run-on / YES NO / YES NO
.
Financial Support
The amount of financial assistance you will receive is dependent on your personal circumstances. It is intended to help you with the costs of overcoming any financial barriers you may have when attending learning.
Please indicate what financial support you require:-
Type of Support Required: / Amount:
Course Equipment / £
Course Fees / £
Food / £
Protective Clothing / £
Transport / £
Trips / £
Other / £
BANK DETAILS
Please provide your bank details below, as printed on your bank card or statement.
Bursary payments will be paid direct into a student’s bank account only. Please not that a provider can choose to pay bursary awards ‘in kind’ e.g. by purchasing any equipment required or providing students with a travel pass.
Bank/ Building Society Name:
Sort Code: / - / -
Account Number:
8) Declaration by student –please read and sign the declaration below
  • The information I have given on this form is correct, true and accurate to the best of my knowledge.
  • I understand that if I provide false or incomplete inf1ormation, I may have to repay any money given to the applicant.
  • I confirm that I am not on a Work-Based Learning or Higher Education course
  • I agree to notify the College of any change in my circumstances which may affect my eligibility for funding, or of any change to my course, as soon as either of these occurs, I will inform the Student Services Team immediately.
  • I understand that the College may claim back all or some of the award made to me if I give misleading or inaccurate information intentionally.I recognise that false statements can leave me open to prosecution.
  • I understand that financial assistance is dependent upon satisfactory attendance and behaviour. I understand that if I withdraw from my course early, I may be asked to pay back some or all of the funding I have received to that date.
  • I understand that any funding I am allocated is for this current academic year only and that a new application will be required for any subsequent years /additional courses.

Signed:
(learner applying for assistance)
Signed:
(Parent / Guardian signature) / Date: //
Date: //
What Happens Next?
Please return your application form to:
Student Services,
Askham Bryan College,
Askham Bryan,
York,YO23 3FR.