Fillable Application for support from the HE Access to (University of Bedfordshire)

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Application for support from the HE Access to (University of Bedfordshire)

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Application for support
from the HE Access to
Learning Fund
Academic year 2019/2020
Date of receipt: Enquiry No: Closing date 26 June 2020
IMPORTANT
• Read the accompanying guidance notes before completing this form.
• Your application will not be considered if you do not answer all the appropriate sections and attach copies of all
required documents (see guidance notes and checklist).
• A
nswer all the questions, by printing clearly in black ink and by ticking the appropriate boxes.
Applications for Student Money Advice can be handed in at any Student Information Desk (SiD) on any
campus and Student Support Reception, P0.31a for Bedford students.
Part 1 Your personal details
1
Student Identity Number
2
Your title (tick one box only)
Mr
Mrs
Miss
Ms
Other
3
Your first names (in full)
4 Your surname (in full)
5 Your date of birth (DD/MM/YYYY)
6 Y
our age (in years) on 01/09/2019
7 Y
our home address
Postcode
8 Your term time address
Postcode
9 Telephone / mobile number
10 E-mail address
Part 2 Course details
11
Course title
12
Campus
13
Are you studying?
Foundation
Undergraduate
Postgraduate
Full time
Part time
Distance Learning
14
How many days do you attend University each week?
15
Start date of course (DD/MM/YYYY)
16
End date of course (DD/MM/YYYY)
17
Year of course (e.g. 0, 1, 2, 3)
18
Please tick here if this is a repeat year
19
Is this your final year?
Yes
No
20
Will you be attending placements during this academic year?
Yes
No
If YES please complete and return the supplementary Placement Form (Part 9) indicating if these costs
can be reclaimed from the faculty or NHS; providing evidence/details of refundable sum.
Part 3 Living arrangements
21 Do you live:
alone? (excepting children)
in a hall of residence?
with your partner or spouse?
with your parents or guardian?
in shared accommodation?
If in shared accommodation, how many other adults live at this address?
Do you share all household expenses?
Yes
No
Part 4 Your dependants
* Evidence required
(If you need to, continue on a separate sheet and attach it to this form.)
22 Do you have any children living with you who are financially dependent on you, whom you receive benefits* for?
Full name
Date of birth
Yes: Give details below No: Go to 23
Part 5 Disability/Special medical needs
(If you need to, continue on a separate sheet and attach it to this form.)
If you completed Part 5 above, please read below and sign if you give consent to share.
Please note that under the General Data Protection Regulation (GDPR) and the Data Protection Act 2018, we need
your explicit consent in order to process the information you provide us with in this form, and any evidence you submit
in support of it.
We will only share your information with the relevant department dealing with your case, and will only use it to
determine whether you qualify for the Access to Learning Fund. Any data you provide us with will be kept for 7 years
after submission and then securely destroyed. If you would like to know more about how we use your data, please see
our FAQ’s.
I consent to the information I provide in this form, and any supporting evidence, being processed by the University for
the above purpose.
Your signature Date
Type your name if submitting an electronic copy
23
Do you have any adults living with you who are financially dependent on you, who are eligible for benefits*?
Full name of adult dependent
Their date of birth
24 Have you been identified as a young adult carer?
Full name of cared for person
Their date of birth
25
Do you have a disability or chronic medical condition (including a long-term health
condition, mental health condition or specific learning difficulty)?
Yes
No
26
Have you applied for Disabled Students’ Allowance (DSA)?
Yes
No
27
Do you wish to apply for financial assistance towards specialist equipment or other by DSA, or to help with the
cost of a diagnostic assessment (e.g. dyslexia), and have you contributed initially towards these costs?
Yes No
If you do not have any Disability / Special medical needs, go to Part 6. If you have ticked yes in questions
25 – 27, please give details below and provide evidence.
Yes: Give details below No: Go to Part 5
Yes: Give details below No: Go to 24
£
£
£
£
£
£
Part 6a Your income (in figures)
Indicate frequency: Weekly / Monthly / Yearly
and complete all boxes with figures or £0 or N/A
Please provide ALL relevant documents
Maintenance Grant or Special Support Grant
Maintenance Loan
NHS Bursary
Social Work Bursary/PGCE
NHS Learning Support Fund
NHS Exceptional Support Fund
Postgraduate Loan
Parents Learning Allowance
Dependants Grant/Allowance
Childcare Grant/Allowance
Teacher Training Bursary
Bursaries/Scholarships/Trusts/Grants*
(Please detail all)
*If any have been awarded to meet specific costs (e.g.
accommodation, travel) please explain what it has been
awarded for:
Disabled Living Allowance (DLA)
Net earnings/NHS salaried students
Parental/Partner contribution
CSA/Child Maintenance
Child Tax Credits
Working Tax Credits
Housing Benefit/Local Housing Allowance
Council Tax Benefit
Income Support/Jobseekers’ Allowance
Universal Credit
Professional Career Development Loan
Disability benefits (please specify)
Other income/savings
(Please specify)
Part 6b Partner’s income (in figures)
Indicate frequency: Weekly / Monthly / Yearly
and complete all boxes with figures or £0 or N/A
Net earnings
Other
Overall total 6A+6B
Please provide ALL relevant evidence for partner
Part 6c Your expenditure (in figures)
(and include partner’s if applicable)
Indicate frequency: Weekly / Monthly / Yearly
and complete all boxes with figures or £0 or N/A
Composite Living Costs (see guidance notes)
Food/Household/Laundry
Gas
Electricity
Water
Telephone
TV Licence
Variable Living Costs (see guidance notes)
(Evidence of following required)
Weekly / Monthly / Yearly
Council Tax
Rent/Mortgage
Childcare costs
CSA/Child Maintenance
Public travel costs (daily travel to University)
Travel costs to placement
Private vehicle costs to University
(road tax/fuel/insurance/maintenance etc)
Partner’s travel costs
Books/equipment/course costs
(including photocopying)
Carers
Disability costs not covered by DSA
(Please specify)
Other costs e.g. minimised debts/repayments
Total Total
Part 7 Supporting statement
28 State why you are in financial difficulty and why you believe your situation to be exceptional, and to merit
additional support. Subject to funding available. [Without a supporting statement your application is
incomplete and cannot be assessed].
Part 8 Bank/Building Society details
You must:
Supply copies of your last three months consecutive bank statements relating to all your accounts and/or bank
closure letters for this academic year (including final statements), for you and your partner/spouse as applicable,
including current balances.
Please explain all debits and credits of £100 and over (including transfers) which appear on statements.
Bank statements are required for other accounts where transactions are shown on your bank statements, if these are
not accounts held by you, a written explanation is required.
These statements must show your name and bank details – mini statements and screen shots are not acceptable.
You are required to supply copies of your last three months bank statements / savings books for all accounts
you currently have including current balances.
Applications submitted without relevant bank statements will not be considered.
1 Name of Bank/Building Society Current Balance Overdraft Limit
Sort Number: Account Number:
2 Name of Bank/Building Society Current Balance Overdraft Limit
Sort Number: Account Number:
3 Name of Bank/Building Society Current Balance Overdraft Limit
Sort Number: Account Number:
4 Name of Bank/Building Society Current Balance Overdraft Limit
Sort Number: Account Number:
Continue on a separate sheet for all other bank accounts, including partner’s.
Access to Learning Fund
Part 9 Placement Form
Placement 1
School/Organisation name:
Dates: From: To: Days per week: Total weeks:
Mileage:
Address:
Postcode:
Placement 2
School/Organisation name:
Dates: From: To: Days per week: Total weeks:
Mileage:
Address:
Postcode:
Placement 3
School/Organisation name:
Dates: From: To: Days per week: Total weeks:
Mileage:
Address:
Postcode:
Mode of transport: Car Car share Public transport On foot Other
Evidence/details of costs required, or expenses cannot be included:
If car sharing please list names of students sharing:
If using public transport please specify: Daily / weekly costs: £
Evidence/details of costs required, or expenses cannot be included:
Can these placement travel costs be re-claimed? Yes No [Check with course administrator]
Evidence/details of amount to be refunded or expenses cannot be included:
Is this a paid placement: Yes No £
Evidence/details required or expenses cannot be included:
Student Name: ID Number:
Student Signature: Date:
N.B: If any placement addresses are still to be confirmed at the time of submitting this form, please still complete
placement dates and update Student Money Advice on the location at a later date by emailing:
studentmoney@beds.ac.uk
Part 10 Supporting Evidence Checklist
Please provide the following legible evidence as appropriate:
Student Finance Breakdown letter from Student Finance England / EU with all details (CRN, name, course etc)
Payment Timetable letter from Student Finance England with all details (CRN, name, course etc)
NHS / Social Work / other Bursary letter (Pre and post 2017 cohorts)
Evidence of the NHS Learning Support Fund / Exceptional Support Fund
Postgraduate Student Loan notification from Student Finance England
Postgraduate Career Development Loan or Research Council Grant
Childcare / Dependants’ Grant / Allowance notification
Evidence of Bursaries / Scholarships / Trusts / Grants
Evidence of all benefits claimed for you / your partner / dependent – including Tax Credit letters etc
Evidence of partner’s income
Current Council Tax schedule
Signed tenancy agreement / mortgage agreement letter
Evidence of childcare costs i.e. child minder contract / letter from childcare provider / receipts
Evidence of CSA contributions / Child Maintenance Service costs / maintenance costs
Evidence of University related travel costs (1 weeks travel tickets or receipts / valid car insurance certificate)
Placement notification and attached fully completed placement form
Evidence of partner’s travel costs (1 weeks travel tickets or receipts / valid car insurance certificate)
Evidence of being a young adult carer and whom for
Evidence of Disability and receipts for Diagnostic tests / specialist equipment
Evidence of minimised debt repayment plan
Evidence of any other current relevant financial information i.e. eviction / housing arrears
Three months Bank / Building Society statements for all accounts with written explanations over £100
Three months Bank / Building Society statements for all partner’s accounts with written explanations over £100
EU, Part time and Postgraduate students only:- Evidence of earnings
Any other supporting evidence – please give details
Part 11 Declarations
I certify that to the best of my knowledge, I meet the following conditions: (tick and complete ALL sections)
SECTION A
i) I am a UK national/British citizen/have long residence in the UK
1
; or
ii) I am settled* within the United Kingdom (UK) (i.e. I have the Right of Abode in the UK or have been
awarded Indefinite Leave to Remain [please provide a copy of your UKBA award notice], or
iii) I have been recognised by the UK Government as a Refugee [please provide a copy of your UKBA
award notice], or
iv) I have been granted Humanitarian Protection (HP) by the Home Office [please provide a copy of your
UKBA award notice], or
v) I am an EEA or Swiss Migrant Worker or the family member of an EEA or Swiss Migrant Worker
(Please tick if you intend to continue working while studying), or
vi) I am an EU national who has been ordinarily resident in the UK for the five years prior to the first day of
the first academic year of my course, or
vii) I am an EU national without five years prior to the first day of the first academic year of my course, or
viii) [a] I am the child of a Swiss national, or [b] I am the child of a Turkish worker
1
‘long residence’ – under 18 and lived in UK for at least 7 years, or over 18 and spent at least half your life in the UK,
or at least twenty years in the UK on the first day of the first academic year of course.
* ‘settled’ – on the first day of the first academic year of course.
SECTION B
I was ordinarily resident** in England, Scotland, Wales or Northern Ireland on the first day of the first academic
year of the course, and
I fall under either (i), (ii), (iv) or (vi) above and I have been ordinarily resident in the UK and Islands for the five
years immediately before the first day of the first academic year of my course***, or
I fall under (iii) above, or
I fall under (v) or (vii) above and I have been ordinarily resident in the EEA and Switzerland for the three years
immediately before the first day of the first academic year of my course, or
I fall under (viii) above and I have been ordinarily resident in the EEA, Switzerland and Turkey for the three
years immediately before the first day of the first academic year of my course.
** ‘Ordinarily resident’ is interpreted to mean habitual and normal residence from choice and for a settled purpose
throughout the prescribed period, apart from temporary or occasional absences. Such residence must also be lawful
– that is, not in breach of any leave to remain in the UK. (Persons awarded refugee status or humanitarian protection
must have been ordinarily resident in the UK from the date this status was granted).
*** None of this time was wholly or mainly for the purpose of receiving full-time education, or if it was, I was resident
in the EEA immediately prior to this five year period.
Part 11 Declarations (continued)
SECTION C
I confirm that I am registered and in attendance on the course described in this form.
plus (as appropriate)
I confirm that I am supporting the children named in Part 4 of this form.
I confirm that I am not living with a spouse/partner (where relevant).
and
I declare that the information that I have given on this form is correct and complete to the best of my knowledge.
Confidentiality
It should be noted that the University observes a corporate policy of student confidentiality so, while applications for
financial assistance may be received initially by members of the Student Support team, all applications, decisions and
records are dealt with by Student Money Advice in the strictest of confidence.
Data Protection Act 2018 / General Data Protection Regulation (EU) 2016/679
Please note that under the General Data Protection Regulation (GDPR) and the Data Protection Act 2018, we need
your explicit consent in order to process the information you provide us with in this form, and any evidence you submit
in support of it.
We will only share your information with the relevant department dealing with your case, and will only use it to
determine whether you qualify for the Access to Learning Fund.
Any data you provide us with will be kept for 7 years after submission and then securely destroyed.
If you would like to know more about how we use your data, please see our FAQ’s.
I consent to the information I provide in this form, and any supporting evidence, being processed by the University
for the above purpose.
I understand that giving false information and/or withholding information could automatically disqualify my application
and may also lead to disciplinary procedures resulting in possible expulsion from the University and action being taken
to recover any awards received. Furthermore, I acknowledge that Student Money Advice may seek further evidence
necessary to substantiate my application at any time during this process.
Any awards are subject to available funding.
Your name (CAPITALS)
Your signature Date
Type your name if submitting an electronic copy
We will contact you by email notification via SiD.
It is your responsibility to check your student email account regularly for updates/progress of your
application, failure to do so may result in delays or closure of your application.
If you would prefer to be contacted by post please tick the box
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Application for support from the HE Access to (University of Bedfordshire)

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