Hardship Funds Application Form

Transcription

1 Hardship Funds Application Form Important Read the accompanying guidance notes before completing this form; which are located on the website. Your application will not be considered if you do not answer all the appropriate sections and attach copies of all supporting documents. Answer all the questions, by printing clearly in black or blue ink and by ticking all the appropriate boxes. Return your completed form to the Financial Welfare & Funding Office FW151 Part 1: Your personal details 1. Student registration number Title (tick one box only) Mr Mrs Miss Ms Other 3. First Names (in full) 4. Surname (in full) 5. Gender Male Female 6. Date of birth (DD/MM/YYYY) 7. Age (in years) 8. Full term time address Postcode 9. Telephone number 10. address Office use OFFA UG Funds International Fund T1 Non OFFA UG Funds Indian SubCon Fund T2 PG Fund Principals Hardship Fund T3 REF Surname: First Name: Year:

2 Part 2: Course details 1. Course title 2. Department 3. Are you: Undergraduate Postgraduate 1. Are you studying: Full time Part time 2. Year of course (e.g. 1,2,3) 3. Are you a repeat year student Yes No 4. Is this your final year of study Yes No Part 3: Living Arrangements 1. Do you live: alone in halls of residence your parents/guardian your partner or spouse shared accommodation 2. If you share accommodation, how many other adults live at this address? 3. Do you share all household expenses? Yes No Part 4: Disability/Special medical needs 1. Do you have a disability or chronic medical condition? Yes No 2. Have you applied for Disabled Student s Allowance (DSA)? Yes No 3. Do you wish to apply for any financial assistance towards any special equipment / material not covered by DSA or for assistance towards the cost of a diagnostic test (e.g. Dyslexic students) Yes No If yes, please give details: Part 5: Your dependants 1. Do you have any children who are financially dependant on you? Yes (give details) Full name: Date of birth: No (if you need to, continue on a separate sheet and attach it to this form) 2. Do you have any adults who are financially dependant on you? Yes (give details) Full name: Date of birth: No (if you need to, continue on a separate sheet and attach it to this form)

3 Part 6: Supporting statement 1. State why you are in financial difficulty and why you believe your situation to be exceptional, and to merit additional support.

4 Part 8A: Student s income (per year or month) Maintenance Grant Bursary from University* Student Loan Parents Learning Allowance/ Lone Parents Grant (PLA/LPA) Adult Dependants Grant (ADG) Childcare Grant (CCG) Disabled Student s Allowance (DSA) Net Earnings Parental/ Partner contribution Child Tax Credit/ Working Tax Credit Child Benefit Housing Benefit/ Local Housing Allowance/ Council Tax Benefit Income Support/ Jobseekers Allowance Professional & Career Development Loan Scholarships/Trusts/ Grants Part 8B: Partners income (if applicable) Net earnings Other Overall total (8A + 8B) Part 8C: Student (and partners) expenditure Composite Living Costs (Per Month) Food/ Household/ Laundry Gas Electricity Water Telephone TV License Contents Insurance Council Tax Fees Rent/ Mortgage Childcare Costs Travel Costs (home to uni) (please specify) Disability benefits (please specify) Other income/ savings Travel Costs (daily travel during term time) Private vehicle costs (road tax/fuel/insurance/ maintenance etc) Books/ Equipment / Course costs (inc photocopying) Disability costs not covered by DSA (please specify) Insurance (excluding car/contents insurance) been awarded to meet specific *If a bursary has Other costs (please specify) Total

5 Part 9: Third Party Payment Request If I am successful with this application and I have debts to a third part (including Royal Holloway) please first pay: Signature: Part 10: Bank/Building Society details Name of Bank/Building Society Sort Code Branch title (e.g. Name of town) Account Number You must supply copies of your last three bank statements relating to the above account. These statements must show your name and bank details mini statements are not acceptable. You will be required to supply copies of the last three bank statements for any other accounts you have. Please explain any debits or credits over 100 that appears on your statements. Applications submitted without relevant bank statements will not be considered. Applications are seen only by the Committee and the Student Finance and Funding office. It may be necessary for additional supporting information to be sought from other university staff in order for the Committee to reach a decision. Royal Holloway is a data controller in terms of the 1998 legislation. The Student Finance and Funding office follows University policy in matters of data protection. The data requested in this form is covered by the notification provided by the University under the Data Protection Act. Personal data will be used solely in the department for statistical purposes and electronic records keeping. The data will not be passed to any other third party without your consent, except when the University is required to do so by law. Any formal enquiries concerning the use of data noted here should be addressed to the Head of Support and Advisory Services. Part 11: Declarations I certify to the best of my knowledge, I fulfil the following criteria: (please tick the relevant boxes) I am a UK National There are no restrictions on my stay and I am therefore *settled within the UK (i.e. Have the Right to Abode in the UK or have Indefinite Leave to Enter/Remain (ILE/R) in the UK). I am an international student I have been recognised by the UK Government as a Refugee and have Full Refugee status/ile/r as a result. I have Exceptional Leave to Enter/Remain in the UK/Humanitarian Protection/Discretionary Leave (ELE/R/HP/DL). I am the child of an EEA Migrant Worker or Swiss employed person. If you hare an EEA Migrant Worker or Swiss employed person, please say whether you intend to continue working while studying. *settled on the first day of the first academic year of your course. Plus I have been Ordinarily Resident within the UK and Islands for 3 years immediately before the start of my course. (anyone with ELE/R/HP/DL or anyone recognised by the UK Government as a Refugee should have maintained Ordinary Residence/ 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 three year period. And I confirm that I am supporting the children I have named in Part 4. I confirm that I am not living with a spouse/partner. I confirm that I am registered and in attendance on the course described in Part 2 of this form. I declare that the information that I have given on this form is correct and complete to the best of my knowledge. 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 loans/grants obtained by me as a result. Your name (CAPITALS) Your signature Date