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Stamp date application received
Reg Status ......
Exp End Date ......
APPLICATION for FINANCIAL SUPPORT 2016/2017
DSA Personal Contribution Reimbursement Form

You can apply for a reimbursement of up to £200 from the University to reimburse your DSA personal contribution.

Making an application:

  1. Read the Guidance Notes on
  2. Complete this application and make sure you answer all the relevant questions fully.

If you have difficulty completing this form please call Disability & Dyslexia Support Services on 0114 2221303, visit.Disability and Dyslexia Support Service,The Hillsborough Centre, Alfred Denny Building, Western Bank, Sheffield, S10 2TN

PERSONAL DETAILS

  1. Student Registration Number: ………………………………………………
  1. Your Full Name: ………………………………………………………………………………………………………….
  1. Your Date of Birth: ……/……../………..
  1. We will email the decision of this application to your University email account. A letter can be provided to your term time addressif you prefer. Please ensure the University has your most up-to date term address.

Tick this box only if you require notification by letter.

  1. Preferred Contact Telephone number: …………………………………………………………….
  1. University Email Address: ……………………………………………………………………………………………...

(Please check your email on a regular basis, we may wish to contact you for additional information to support your application or give you up to date announcements)

PERSONAL INFORMATION AND CIRCUMSTANCES

Please use the space below to add any comments you feel would be relevant to this application: (This is not compulsory)

CHECKLIST OF EVIDENCE REQUIRED

As part of your application you must providethe following documents, all proof MUST be enclosed to make your application complete. Incomplete applications will not be considered. Please indicatebelow the evidence you have enclosed with this application.

1.Your DSA letter

Please provide your DSA letter from SFE, SFW, SFNI, SAAS or NHS. Please email this document to . Ensure you include the page which indicates you are liable to pay the £200 contribution.

2.All Students must Read, Sign and Date the form Declaration.

CONFIDENTIALITY

Applications are only seen by Student Services Staff and the Financial Help Advisory Panel, if necessary. In some cases it may be necessary for additional supporting evidence to be sought by yourself from other university staff in order for the Panel to reach a decision.

DATA PROTECTION ACT 1998

The University of Sheffield is a data controller in terms of the 1998 legislation. The Student Services Department follows University policy in matters of data protection. The data requested in this form is covered by the notification provided by the University under the Data Protection Act. Personal data will be used solely in the department for statistical purposes and electronic records keeping.

The data will not be passed to any third party without your consent, except when the University is required to do so by law. Should you have any concerns as to how this information is used please contact the Student Services information Desk, Students’ Union.

  • I have read all the documentation included with this application, including guidance notes.
  • I declare that the information I have given on this form is true, complete and accurate.
  • I understand that providing false information in an attempt to obtain funds from the University, BIS (Business Innovation & Skills) or other funding body would be fraudulent and could result in disciplinary action and will automatically disqualify my application.
  • I will contact the University if my circumstances change in any way.
  • I have enclosed documentary evidence in support of my application and understand that my application will not be processed without adequate evidence.

SIGNED…………………………………………………………………………………….DATED……………………………….

RETURN THIS FORM and attach your documentationto: Student Support and Guidance, Level 6, Students’ Union, Western Bank, S10 2TN.MONDAY – FRIDAY before 4:30pm orby email to and scanning your documents.

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