Application for support from the Further Education Learner Support Fund

Application year 2011/12

Surname

First Name P Number

Money and Welfare

For office use only: Date received Method of receipt/ Adviser

Further Education Funding

Age of student Aged 1619*

* you need to be under 19-years-old st on 31 August 2011

What you need help with Books/equipment Transport Subsistence

What you can apply for

1619 Bursary Fund

Aged up to 19 (and including 19) when learning starts

Childcare

Care to Learn supports young parents by funding the cost of Ofsted-registered childcare and associated transport costs. Further information can be found by telephoning the helpline on 0800 121 8989.

Accommodation* Aged 1618

* if you have moved away from home to do the course

F.E. Learner Support Fund

(See Parts 3 and 4 of this form)

Aged 19

Books/equipment Travel Accommodation*

* if you have moved away from home to do the course

F.E. Learner Support Fund

(Please complete all the relevant parts of this form)

Aged 20 or over

Books/equipment Childcare Travel Accommodation*

* if you have moved away from home to do the course

F.E. Learner Support Fund

(Please complete all the relevant parts of this form)

The 1619 Bursary Fund application forms are available from Lorraine Jones, Foundation Studio, Room 1.74.

Application for support from the Further Education Learner Support Fund 2011/12
Please fill in the application clearly and provide photocopied evidence where requested. We will not be able to accept original documents. Please note that there are limited funds available and awards will be made on a first-come-first-served basis. Closing date is Friday 18th May 2012.

Part 1: Your Details this must be completed by ALL applicants

DMU Student Number Title (tick one box)

P
Mr Mrs Miss Ms

Other (please state) First Name Surname Gender M F Date of birth (DD/MM/YY)

How old will you be on 31st August 2011? Tick here if you are a care leaver or estranged from your parents PLEASE NOTE: In most cases we will contact you by email. We will use your DMU email account (this is due to previous technical problems with other email providers). We can obtain your email address from the central records. Alternatively, please tick here if you would prefer us to contact you by letter to your correspondence address (below) Your full correspondence address

Postcode Telephone

Part 1: Your Details (continued) this must be completed (if applicable)

Please provide details of any of your children aged 18-years-old or under, who live with you: Full name(s) Age(s)
PHOTOCOPIED Evidence Required:
Child Benefit letter for 2011/12

Part 2: Disability/Medical Conditions

If you have a disability for which you are claiming a Welfare Benefit, please specify the nature of your disability below:
PHOTOCOPIED Evidence Required:
Recent DWP letter or Jobcentre Plus letter

If you have an illness or medical condition which restricts your ability to work, but for which you are not claiming a Welfare Benefit, please specify the nature of your medical condition below:

A letter from your GP or medical practitioner confirming your illness or medical condition or Proof of ongoing treatment

Part 3: Course Details this must be completed by ALL applicants

Course Title 1 Did you move away from home specifically for your course? No Yes If No please go to Part 4: Accommodation Costs If Yes please answer Question 2 below
Question 2 evidence: Proof of enrolment Proof of hometown address Question 3 evidence: Letter from Tutor; or UCAS application letter; or Offer of place on DMU degree course

PHOTOCOPIED Evidence Required:

2 Did you move away from home because there wasnt a course like this available in your hometown? No Yes If No please answer Question 3 below If Yes please provide the evidence listed in the box

3 Do you intend to continue onto undergraduate studies at DMU? No Yes If No please go to Part 4: Accommodation Costs If Yes please provide the evidence listed in the box

Part 4: Accommodation Costs this must be completed by ALL applicants

Please indicate your term-time living arrangements: Alone With Parents/Guardian With Partner/Spouse Halls of Residence
PHOTOCOPIED Evidence Required:

If you live away from home during term-time, how much rent do you pay per month?

If you live away from home during term-time and pay rent: Tenancy Agreement for 2011/12

Part 5: Your Income this should ONLY be completed by Independent students

You will be required to fill in this section if the following applies: You are over 25 years old; or You are under 25 years old and meet one or more of the following criteria: you have children you have a disability you have lived independently from your parents/guardian for three years you are estranged from your parents/guardian your parents have died. Please calculate the projected figures below to cover 12 months including the 2011/12 academic year Earnings (gross) Savings Education Maintenance Allowance Adult Learning Grant Income Support Jobseekers Allowance (JSA) Employment Support Allowance (ESA) Incapacity Benefit Housing Benefit Council Tax Benefit Tax Credits Other (please state)
Benefits: Tax Credits (all pages) for 2011/12 Housing Benefit documents 2011/12 Council Tax Benefit documents 2011/12 Do not supply Child Benefit or DLA Bank statements: 3 months most recent bank statements for ALL accounts you hold

PHOTOCOPIED Evidence Required:

Proof of your independent status: Documentation which supports one or more of the categories listed on the left If you have Earnings: 3 most recent wage slips If you have Savings: 3 months most recent bank statements for ALL your savings accounts If you are still receiving EMA: Relevant paperwork If you are still receiving ALG: Relevant paperwork

Total

Part 6: Parental/ Partners Income to be completed by ALL applicants (if applicable)

This section must be filled in by: your Parents (if you are under 25 years old and not an independent student) your Partner (if you are an independent student, and have a partner) Person 1 Relationship to student: First Name: Surname: Address: Person 2 Relationship to student: First Name: Surname: Address:

Postcode:

Postcode:

Please calculate the projected figures below to cover 12 months including the 2011/12 academic year Income for Person 1 Earnings (gross) Benefits* Tax Credits Pension/Pension Credits Unearned Income** Savings Other (please state) Total Income for Person 2 Earnings (gross) Benefits* Tax Credits Pension/Pension Credits Unearned Income** Savings Other (please state) Total

* Please do not include Child Benefit or DLA ** Unearned Income refers to activities such as income from lettings PHOTOCOPIED evidence required: P60/ or 3 most recent payslips/ or Statement of Earnings (if self-employed) DWP/ Local Authority letter regarding Benefits Tax Credits award letter for 2011/12 (all pages) Pension income details Other income and savings details

Parents/ Partners Declaration

I believe, to the best of my knowledge, that the information supplied above is accurate. Signed (Person 1) Signed (Person 2)

Date

Date

Part 7: Registered Childcare Costs

This applies to students 20 years old or over (students under this age will have access to the
Governments Care to Learn Programme see inside front cover of this form for more information).

Please get your childcare provider to complete this section. Child 1: Weekly Cost Name of Child Name and address of registered childcare provider Telephone Number Providers Signature Print name
(in block capitals)

OFSTED Registration Number

Child 2: Weekly Cost Name of Child Name and address of registered childcare provider Telephone Number Providers Signature Print name
(in block capitals)

OFSTED Registration Number

Child 3: Weekly Cost Name of Child Name and address of registered childcare provider Telephone Number Providers Signature Print name
(in block capitals)

OFSTED Registration Number

Part 8: Travel Costs this must be completed ONLY by applicants aged 19 and over
How do you travel to DMU from your term-time address? Car Train Bus Cycle/Walk
PHOTOCOPIED Evidence Required:
If you travel by car: Current (valid) Motor Insurance Certificate If you travel by bus: At least three bus tickets; OR A copy of your travel pass and receipt confirming the price If you travel by train: At least three train tickets; OR A copy of your travel pass and receipt confirming the price

Other (e.g. car share), please state below:

PLEASE NOTE: if you are under 19-years-old and need help with travel costs, please refer to other funding you might be able to apply to, listed on the inside front cover.

Part 9: Your Bank Details this must be completed by ALL applicants

In order for us to make an award by BACS Transfer we will require your bank details. Please fill in your details in the spaces provided: Name of Bank Account Number Your name (as it appears on your account) If you do not have a bank account or building society account, please tick here Sort Code

Important please read

Please do not forget to include all the requested evidence as photocopies Your application form will be returned to you if it is not complete Please submit your application form at the earliest possible time as funds are issued on a first-come, first served basis and can sometimes run out well in advance of the closing date Final date for submission (subject to available funds) is th

Friday 18 May 2012

Forms to be returned to: Money and Welfare, Student Services, Gateway House, De Montfort University, Leicester LE1 9BH Opening Hours: Monday to Friday, 9am to 5pm

DATA PROTECTION ACT 1998

The University collects information about students for various administrative, academic and health and safety reasons. Because of the Data Protection Act we need your consent before we can do this. Since we cannot operate the University effectively without processing information about you we need you to sign the following consent to process clause. I agree to De Montfort University processing personal data contained in this form or other data which the University may obtain from time-to-time from me or other people whilst I am a student. I agree to the processing of this data for this application.

Part 10: Declarations this must be completed by ALL applicants

I certify that to the best of my knowledge: I have read and fully understood the Data Protection Act 1998 statement above I am a home status student (for the purposes of fee payment) I declare that the information I have given on this form is correct. I understand that giving false information will automatically disqualify my application and may also lead to disciplinary procedures resulting in possible expulsion from the University. I further undertake to repay any grants obtained by me as a result. I also realise that if I leave the course early, or fail to attend on a regular basis, I undertake to repay any grants obtained by me. Your Name (in capitals) Your signature Date

FOR OFFICE USE ONLY: Advisers Notes (please date and initial next to each note)

For Office use only:

For Office use only:

1618 years
Income Student Income Partner Income Parent 1 Income Parent 2 Income Total % Award Residential Bursary Award granted

19 years 19 years
Income Student Income Partner Income Parent 1 Income Parent 2 Income Total

19

% Award Residential Bursary Award granted Hardship Books/equipment Total Mileage Travel Costs Total

Award Calculation L.A.C? + Residential

Award Calculation L.A.C? + Residential + Hardship

= Percentage Total Award Signed Date

Percentage Total Award Signed Date

For Office use only:

ForFOR OFFICE USE ONLY: Advisers Notes Office use only:

20 years or over
Income Student Income Partner Income Parent 1 Income Parent 2 Income Total % Award Residential Bursary Award granted Hardship Books/equipment Total Mileage Travel Costs Total Childcare Award granted

19 years

Award Calculation L.A.C? + Residential + Hardship + Childcare = Percentage Total Award Signed Date