Fillable Sfni Dsa Slimline Form 2122 O (London Institute of Management and Technology)

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Sfni Dsa Slimline Form 2122 O (London Institute of Management and Technology)

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DSA
Disabled Students’ Allowances
Application Form 2021/22
NIR/DSASL/2122/A 1
What do I need to do to get Disabled Students’ Allowances (DSAs)?
Here is a summary of the steps involved in applying for and receiving DSAs.
Step 1
Complete and return this DSA
application form with evidence of your
disability, mental health condition or
specific learning difficulty.
Step 2
We will assess your application and
send you a letter to let you know if
you qualify for DSAs or not.
Step 3
We will ask you to attend a Needs
Assessment to identify any specialist
equipment and other support that you
may need for your course.
Step 4
If you are eligible for DSA, you attend
your Study Needs Assessment and
receive a report which identifies
any specialist equipment and other
support you may need.
Step 5
We will send you a letter to tell you
whether any specialist equipment
and other support that has been
recommended in your Needs
Assessment Report can be paid for
from DSAs. We will also provide
instructions for ordering equipment or
arranging other support.
Categories of support available through DSA
Delivery
of specialist
equipment
Non-medical
helpers
allowance
General
allowance
Extra travel
costs
2 NIR/DSASL/2122
Where can I find more information about Disabled Students’
Allowances (DSAs)?
Visit www.studentfinanceni.co.uk
You can also find more information in the guide:
• ‘2021/22 DSA students - Bridging the gap: A guide to the Disabled Students
Allowances (DSAs) in Higher Education’.
Braille, large print or audio forms and guides
You can order forms and guides in Braille, large print or audio by emailing
with your name, address, customer reference number along with what form
and format you require to
• brailleandlargefonts@slc.co.uk
or you can telephone us on
• 0141 243 3686
Please note, the above email address and telephone number can only deal
with requests for alternative formats of forms and guides.
How can I contact you?
• Visit www.studentfinanceni.co.uk
• Contact our Customer Support Office on 0300 100 0077
Instructions
•
Whenever you see this icon you must provide evidence to support your
application.
• Answer all questions as fully as possible. If you do not, this may cause a
delay to your application.
NIR/DSASL/2122 3
!
Section 1 - personal details
Customer Reference Number
Forename(s)
Surname
Sex
Male Female
Date of birth
Day Month Year
Section 2 - other nancial support
Bursaries and awards
In academic year 2021/22 will you be eligible to apply for:
• an NHS bursary (excluding the social work bursary paid
by the NHS Business Services Authority)
Yes No
• a Scottish Government Health Directorate Bursary
(Scottish Healthcare Allowance)
Yes No
• a healthcare bursary from the Department of Health for
Northern Ireland
Yes No
If you receive one of these bursaries or awards which includes an element
for disability you will not be eligible for Disabled Students’ Allowances
through Student Finance NI. Do not continue with this application.
Do you currently receive any financial help towards travel costs?
e.g. mobility component of Disability Living Allowance or
Personal Independence Payment
Yes
No
If ‘Yes’ please provide full details including amounts
Type of financial help
Amount (£)
4
Section 3 - DSA information and evidence
Your disability, mental health condition or specific learning
difficulty
a
Please give full details and provide evidence of your disability, mental health
condition or specific learning difficulty.
You can also download and complete the Disability Evidence Form from
www.studentfinanceni.co.uk
Physical disability/mental health condition
You should provide a written medical statement from a doctor or appropriately
qualified specialist, confirming the nature of your disability or mental health
condition.
Specific learning difficulty (for example, dyslexia)
You should provide a diagnostic report, written in accordance with the 2005
Specific Learning Difficulty (SpLD) Working Group Guidelines, from either:
• A Practitioner Psychologist; or
• A suitably qualified specialist teacher, holding a SpLD Assessment Practicing
Certificate.
It is your responsibility to pay any costs to obtain the required evidence.
b
On what date was your disability, mental health
condition or specific learning difficulty last assessed?
Day Month Year
5
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
Section 3 - DSA information and evidence
Continued
c
Is this your first application for Disabled Students’
Allowances (DSAs)?
Yes
No
if ‘Yes’ go to section 4
If ‘No’, please provide details of each previous DSA funding application you have
made.
Date of application
Funding authority applied to
Day Month Year
You must provide evidence showing the result of each previous DSA funding
application and any DSA Needs Assessment Report you received from the
funding authority.
If you cannot provide the evidence requested, please provide full details of the
funding you received in the box below.
We may contact the relevant funding authorities for further information.
6
Section 4 - your consent
Your consent to DSA arrangements
Please tick the boxes below if you consent to the following DSA
arrangements. If you do
not give consent it may delay any payments
you receive.
You have the right to withdraw your consent to us processing your
personal information in relation to this application form. To withdraw
your consent, please contact us.
I agree that Student Finance NI and the disability adviser at my university or
college may exchange information about my application for DSAs where this
is necessary to make sure I get the help I need.
I agree that Student Finance NI and my DSAs Needs Assessor may
exchange information about my application for DSAs where this is
necessary to make sure I get the help I need.
!
I agree that Student Finance NI and my DSAs suppliers may exchange
information about my application for DSAs where this is necessary to make
sure I get the help I need.
Section 5 - your bank or building society account
UK bank/building society account details
Where possible we will pay suppliers of your equipment or support services
directly. However, please complete the section below so that we can pay you if
we need to. You do not need to provide these details if you have already given
them to us.
The account must be in your own name and be able to accept direct
credits.
Sort code
Account number
Building society roll number
(if applicable)
- -
7
Declaration
To find out how we’ll use the information you provide go to
www.studentfinanceni.co.uk/privacy-notice to read our Privacy Notice before
signing this form.
Alternatively, you can request a copy by writing to the Student Loans Company Ltd
(SLC) at 100 Bothwell Street, Glasgow, G2 7JD or by calling our Customer Support
Office.
• I confirm that to the best of my knowledge and belief, the information I have
provided is true and complete. If it’s not I understand I may not receive financial
support, any support I have had may be withdrawn and I could be prosecuted.
Your full name (in BLOCK CAPITALS)
Your signature
Today’s date
x
Day
Month Year
8
Additional notes
If you are providing extra information below please clearly mark what section and
question number the information is about.
9
Checklist
Before returning this form, please make sure you have done the following:
Signed and dated the declaration.
Enclosed all the evidence requested to support your application. Any original
evidence you send will be returned to you as soon as possible.
Please remember to pay the correct postage.
You must return your completed form to your local Student Finance NI
(SFNI) office. You can find their address at www.studentfinanceni.co.uk
10
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Sfni Dsa Slimline Form 2122 O (London Institute of Management and Technology)

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Completed 20 July 2021

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