7/30/2019 16-19 Bursary Application form 1314

1/216-19 Bursary Application form 1314

16-19 Bursary Fund Application Form 2013/2014

This form should only be used for students applying for the Bursary for the first time or who were on the Bursary in

2012/13 and whose financial circumstances have changed and need to provide new evidence for 2013/14. Please

complete and hand in to Duncan Lawton Building Bursary Office by Friday 6 September 2013.

Section 1 Your Personal Details (please complete using BLOCK CAPITALS)

Student ID Number: (only to be completed if known)

First Name(s): Surname:

Gender: Female Male Date of Birth: Age at 31 August 2013

Address:

*(must match

evidence)

Home Tel No: Mobile No:

Section 2 Your Learning Programme

Year of Study: 1st

Year 2nd

Year 3rd

Year

Section 3 Bursary Type

Would you like to apply for either : a CASH Bursary OR a TRANSPORT Bursary

(You must only chose one type of bursary)

Section 4 How you travel to and from College (for students applying for Transport Bursary only)

Which bus company do you use, eg First Buses, System One?

Do you travel to College by the College organised bus from Rochdale? Yes No

Section 5 Your Personal/Family Income

You will need to provide current evidence where you have answered Yes and see this symbol

Please providephotocopiedevidence only and write your name and Student ID number on each page.

Do you live with at least one of your parent(s)/guardian(s)? Yes No

Are you currently in care/classed as a Looked After Child by the Local Authority? Yes No

Have you previously been in Care and now classed as a Care Leaver? Yes No

Do you receive Income Support? Yes No

Do you receive Employment and Support allowance and are also in receipt Yes No

of Disability Living allowance?

7/30/2019 16-19 Bursary Application form 1314

2/216-19 Bursary Application form 1314

Do your parent(s)/guardian(s) receive any of the following benefits:

Education Benefits (Evidence - Benefits Agency/Local Council letter) Yes No

Employment and Support Allowance (Evidence Dept for Work & Pensions letter) Yes No

Income Support (Evidence Job Centre Plus letter/notification) Yes No

Jobseekers Allowance (Evidence Job Centre Plus letter/notification) Yes No

Working Tax Credits for income below 21,000 Yes No

(Evidence HM Revenue & Customs Tax Credit Award Notice for the year

April 2013 April 2014). All 6 pages of this document need to be copied and supplied.

Child Tax Credits for income below 21,000

(Evidence HM Revenue & Customs Tax Credit Award Notice for the year Yes No

April 2013 April 2014). All 6 pages of this document need to be copied and supplied.

Universal Credits (Evidence HM Revenue & Customs Award Notice) Yes No

Pension Credits (Evidence HM Revenue & Customs Award Notice) Yes No

Section 6 Supporting Information

Please use the space below if you wish to give any further information in support of your application

(this is not essential).

Section 7 Declaration

By signing in the box below you confirm that:

The information you have given on this form is, to the best of your knowledge, correct and true. You will inform the Student Services Office in writing of any change to your personal, family or financial circumstances. You understand that if you leave your course early, you will be required to return any money, equipment or travel pass

that has been given to you from the 16-19 Bursary Fund.

You understand that you must meet the terms of the Student Contract and have 90%+ attendance in order to receivesupport.

Students Signature: Date:

Parents Signature Date:

For Office Use

Initials and Date REMS Updated Email sent date

Approved Vulnerable Learner

Approved Cash Bursary

Approved Transport Bursary

Not Approved Reason N/A

Bus Pass: First System One Rochdale