OFFICE USE ONLY / ______/ HEFCE Grant
Standard/Non-standard award:
Reason: / ______/ Non-HEFCE Grant
Authorised Signature:
Date: / ______/ No award
Your URN(shown on Campus Card)

Mr/Mrs/Ms/Miss (pls. circle)

First name:
Last name
Contact Address:
Post code:
Contact phone:
Email address:
Permanent Address (if different):
Bank/Building Society
Sort Code – 6 digits
Account Number – 8 digits

These details will be used by the Finance Department for all future payments & transactions

Course
Faculty
Year / Foundation, 1, 2, 3, 4, 5
(pls. circle)
Are you a final year? / Y / N
Is this a repeat year? / Y / N
Under- or Postgraduate? / UG / PG
Full-time or Part-time? / FT / PT
Do you live:
(please circle) / Alone / In shared accommodation / With partner/spouse / With parents/ guardian
Do you have financial responsibility for any dependent children? / Yes / No
If ‘Yes’ please give full names and dates of birth:
1. ______d.of b. ______
2. ______d.of b. ______
3. ______d.of b. ______
Do you have a disability or chronic medical condition? / Yes / No
If ‘Yes’, have you applied for Disabled Students Allowances (DSA)? / Yes / No
Are you currently on placement? / Yes / No
If ‘Yes’ where is/was your placement?
How many weeks is/was your placement?
Have you applied for or received any financial support from the University this year?
(pls, give details) / Yes / No

You will need to provide evidence to confirm all the items listed in your income and expenditure.

NB: Please supply amounts on a weekly basis.

Income / You / Partner
Student Loan (undergraduate)
Income from parents
grant/bursary/ University Bursary/scholarship
Loans other than those from the Student Loan Company
Net (after tax) earnings from Employment
Professional/Career Development Loan/Scholarship/Trust
Disabled Students’ Allowance(s)
Child Benefit
Child Tax Credit/Working Tax Credit
Income Support/Job Seekers Allowance
Housing Benefit/Council Tax Benefit
Access to Learning Fund Award or other loans already awarded this year
Other (eg child support, disability benefits, grants, etc. – please specify)
Total
If you were on a paid placement during last year please state your total net (after tax) earnings for that year
If you are on a paid placement during this year please state the net (after tax) amount you expect to earn in the year
Do you have overdraft facilities? Yes / No / Account 1 / Account 2
What are the agreed limits?
Of this, how much do you still have available to you?
If you have credit cards, what are the agreed limits on them?
Of this, how much do you still have available to you?
Do you have any other savings or investments of any sort? / Yes / No
Please give details: / Account 1 / Account 2 / Account 3
Bank:

Please complete [on the left hand side] any of the following statements which apply to you.

No. of weeks for calculation (please circle) / 39 / 43 / 45 / 52
Include partner’s figures where relevant

FOR OFFICE USE ONLY

1. Living costs

Composite living costs (e.g. £2,847 for a single student)

2. Accommodation costs

I pay £……………..….. per …...………...... in rent/mortgage (pls. circle)
Ceilings: £130 and £195 (2-bed requirement)

Campus = 37 wks for cont UG/38 for new UG

3. Course costs

A ceiling of £50 for most classroom-based courses is used as part of the calculation

4. Travel

To travel, during semesters, from my ‘university address’ to the university campus costs £………………… each journey
And I do this ……………………………… times a week.

NB: we will use the BusPass price if appropriate

5. Visiting parents/home address

A return journey to my parents’/home address costs
£………………. . I go home ………… times a year

6. Costs associated with transporting dependents

e.g. to and from School/Nursery

7. Childcare costs

My usual childcare costs are £………….. per week
during semesters
NB: only 85% of cost will be offered

8. Vacation childcare costs

During vacation times I have childcare costs of £…………...
Per ……………… because ……………………………….

9. Other costs

During this academic year I have had the following

‘one off’ expenses (e.g. medical, rail card, etc.)

………….…………………………… cost £ …………………..
………….…………………………… cost £ …………………..
………….…………………………… cost £ …………………..

10. Unforeseen/unexpected expenses

Please give details: ………………………..…………………..
…………………………………………………………………….
TOTAL

Please complete a fully as possible

These items may inform the Adviser’s calculation, at Committee discretion

Cost per Week/Month/Year (pls.circle)

Food/Household/Laundry / Insurance
Gas / Electricity
Water / Telephone
Gym card / Entertainment
TV licence / Other (pls. specify):
………………………….

Checklist of Actions:- Has Student signed the declaration?
Has referral for disability support been actioned, where required?

POINTS Points (office use only)

Cant’ work – ill health / 2
Family situation (e.g. lack of family support) / 2
Self funding / 1
Independent/single parent / 1-2
Final Year / 1
Bereavement/family illness / 1
Travel (in excess of the cost of living on campus per year) / 1

[cheapest rent on campus is now £60/wk.)

High accommodation cost (in excess of £130 per week) / 2
Other/SA discretion (specify)
Total points

FOR COMMITTEE USE ONLY -

Summary of financial calculation

Income
Savings
Assumed income
Total income
Total expenditure
Shortfall
Percentage sought
Amount sought
Instalments? If appropriate, dates as follows:-……………
……………
……………

Please give a full explanation of the reasons (unexpected, severe or exceptional) you are seeking financial assistance from the Access to Learning Fund. Remember, a decision can only be made based on the information you give. The more detailed, clearly set out and supported by appropriate documentation your application is, the quicker it can be considered. Please include an explanation of the potential avenues of funding you have already explored. Please continue overleaf if necessary.

Please cont. overleaf/…

DECLARATIONS Please sign and date the form and make an appointment to see a Student Adviser who will discuss your application with you. Your application will not be considered unless you have discussed it with a Student Adviser.

1DATA PROTECTION

Student Advice will treat any personal information which is communicated to it in the course of its work with you as confidential and will keep and use it only for the purpose of administering the Hardship Fund, including co-ordinating and providing support for applicants and taking steps to verify information given in support of Hardship Fund applications.

To comply with Data Protection legislation, Student Advice will only share personal information with appropriate academic, support, residential and other staff, and external individuals and organisations if you give explicit consent (unless there is a legal requirement to do so). However, if you do not give consent, you should be aware that the support which the University will be able to offer you may, therefore, be limited.

This information will be processed securely within the electronic casework system and in accordance with the Data Protection Act 1998.

If you do not wish your information to be kept and used in this way, tick the box below. Please be aware that by withholding consent you may limit the service available to you through Student Advice.

I do not want my details to be managed within the casework system as described above

I hereby give explicit consent to the sharing of my information with relevant members of staff, and external individuals and organisations, for the purposes described above, including preventing the obtaining of monies by deception.

2PERSONAL

I confirm that the information I have given in support of this application and the evidence provided is true and complete to the best of my knowledge and that I am in extreme unforeseen/exceptional/unexpected hardship.

I undertake to notify Student Advice immediately if my circumstances change during the 2011-12 academic year.

I authorise the University, where appropriate, to pay any award to an agreed third party.

Third party (where applicable) is:- ______(student to complete)

I understand that giving incomplete information may disqualify my application. I also understand that giving misleading or false information may automatically disqualify my application, and may also lead to disciplinary procedures resulting in the maximum disciplinary penalty available to the University. I recognise that I will also be required to repay any monies obtained by me as a result of giving misleading, incomplete or false information.

Signed: ______Date: ______

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