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					Access to Learning Fund

Course Contribution Grant & Additional
 Fee Support Application for Part-time
              Students
               2011/12




                                         1
GUIDANCE: YOU SHOULD READ THIS BEFORE YOU FILL IN THE FORM

The Access to Learning Fund is a discretionary fund which may assist with some of your
course costs. You can use this form to apply for a grant. All support is means tested on the
basis of your income and that of any partner who lives with you. Part-time students
normally only receive a contribution towards course related costs as they are expected to
have a source of income available for their living costs such as earnings or benefits.

What are the basic rules?
   You must normally live in the UK
   You must not be seeking asylum or be a failed asylum seeker
   You must be enrolled at the University
   If you are attending a short course it must be your first higher education experience
   You must have applied for any other funding available to you as a part-time student
   If you are studying a Degree, HND, Foundation Degree or Postgraduate course you
     must normally expect to complete the course in no more than twice the time it would
     take to finish if it were full-time (some students with a disability do not need to meet
     this requirement)
   There are some other eligibility criteria so not all applications are successful;
     meeting the above criteria does not automatically mean you will qualify for an award
   Completed applications will be accepted up to two weeks before the end of the final
     term for undergraduate students. Part-time postgraduate students and part-time
     Diploma/Degree in Nursing students may apply after this time
What do I need to do?
   Complete this form answering all the questions honestly
   Provide us with evidence of your income and expenditure (PLEASE NOTE: WE
     ONLY ACCEPT PHOTOCOPIED DOCUMENTS)
   Hand in or send your completed application to the Student Funding Team, Student
     Services, Student Centre Level 1, Teesside University, Middlesbrough, TS1 3BA
   Wait for us to contact you by letter

How long will it take for me to hear the outcome?
   We aim to write to you with the outcome of your application within 15 working days
      from the date you submit your application and/or the final piece of information
      we need
If I am awarded a payment how will I receive it?
      You need to complete the bank details section on this form as most awards are paid
       as a grant directly into your bank account
      If we do not have your bank details you will be sent a cheque to the address you
       have registered with the University

Keeping your information safe
The personal information you give us on this form will be used to process your application
and we may use it for statistical analysis. Your information will not be passed to any third
party outside of the department without your consent (except where we are required to do
so by law). We will act in line with the Student Services Confidentiality Policy.
................................................................................................................................................
RECEIPT (IF REQUIRED) – CCG/AFS form
Student name:                                                               Date received:
Student signature:                                                          Staff signature:
                                                                                                                                              2
Office use only
Date received                                              Form number
Course code                                         HESA ID


YOUR DETAILS
I am studying part-time (please tick the box to confirm this)


You should only complete this form if you are enrolled as a part-time student. If you are
studying full-time please complete the Grant for Living Costs form
Name


Title (eg Mr, Mrs, Ms)                            Age in years on 31 July 2012


Enrolment number


Address whilst attending University (including postcode)




E-mail address


Contact telephone number


ABOUT YOUR COURSE
Name of course (please include title eg Degree, HND)


Year of course eg 1st, 2nd, 3rd
Have you ever attended another Higher Education course (other than your current
course)? Yes         No


If yes please state below any previous courses and qualifications gained


                                                                                            3
ALL STUDENTS MUST ANSWER THIS QUESTION

How do you pay your tuition fees? Please tick one of the boxes:

Pay yourself

Tuition fee grant from Student Finance England or your Local Authority

Have applied to the University Finance Department for a fee waiver

Other (please state)


QUESTIONS FOR FOUNDATION DEGREE, HND/C STUDENT AND DEGREE
STUDENTS

If you are studying a Degree, Foundation Degree or HND/C have you applied for a tuition
fee grant from Student Finance England or your Local Authority?

Yes             No

If no please provide an explanation in the box below as to why you have not applied. If this
is because you already have a higher education qualification please attach a copy of your
certificate




DISABILITY

Do you have a disability, long-term medical condition or specific learning difficulty such as
Dyslexia? Yes            No



Do you receive a disability related benefit for yourself such as Disability Living Allowance,
Incapacity Benefit or Employment Support Allowance? Yes                   No

If yes please provide a copy of your assessment letter

HOUSEHOLD

Do you live (please tick one box only):

                                           Alone?

                 With children but no other adult?

                               With housemates?

          With a spouse, civil partner or partner?

With a spouse/civil partner/partner and children?


                                                                                                4
Please give the following details about those who live with you and with whom you
have a relationship other than housemates eg partner, parents, children. It is very
important that you give this information.

Name                            Relationship to you             Age (please provide date
                                                                of birth and age for any
                                                                dependant children)




INCOME

Do you have any earnings? Yes                 No

If yes how much do you earn on average per week?

If you have a spouse, civil partner or cohabiting partner does s/he have any earnings?

Yes            No

If yes how much does s/he earn on average per week?

If you have a spouse, civil partner or cohabiting partner is s/he a full-time student?

Yes            No

If yes where is your partner studying?




                                                                                           5
Do you or any partner with whom you live get any of the following benefits?

Benefit                                       Yes         No            Weekly amount
Housing Benefit/Local Housing Allowance
Income Support
Job Seekers Allowance
Incapacity Benefit
Disability Living Allowance
Carers Allowance
Child Tax Credits
Working Tax Credits
Employment Support Allowance
Other (please state)


Do you or any partner with whom you live have any other income?

Income                                        Yes         No            Weekly amount
Child support arranged through the
CSA/Courts
Informal child support
Pension credits
Occupational pension
Part-time NHS Bursary
Contribution from a partner or parent(s)
Other (please state)


CHILDREN (PLEASE COMPLETE IF YOU USE REGISTERED CHILDCARE)

What is your childcare provider registration number? If you use more than one provider
please provide all numbers



Do you want to apply for help with the cost of childcare whilst studying?

Yes           No

If yes your childcare provider will need to complete the next page and you will need to
provide a copy of your child(ren)’s birth certificate(s).

Do you or any partner with whom you live receive the childcare element of Working Tax
Credits? Yes           No



Please note that if you receive the childcare element of Working Tax Credits you may not
qualify for help towards childcare costs from the Access to Learning Fund.




                                                                                           6
SECTION TO BE COMPLETED BY THE CHILDCARE PROVIDER

What is your registration number?

Please provide your details below

Your name



Address where childcare is provided




Contact telephone number



E-mail address



How much does the student pay towards childcare at the following times of the year? The
boxes below should be completed with the weekly amount and number of weeks at the
given time of the academic year

Time of year                             Weekly amount          Number of weeks out of 52
During student’s term time

During student’s placements (if
applicable and different from the
student’s term time)
During the child(ren)’s school
holidays (if different from term time)

Please give the name(s) of the student’s child(ren) you care for



Please give the name of the student you provide childcare for



Please sign and date the declaration below

I confirm that I provide childcare at the cost detailed above. I have read the information
below:

Signed                                     Date



Information for the childcare provider: please note that awards are made to the
student and not the childcare provider. It is the student’s responsibility to pay you.
                                                                                             7
EVIDENCE CHECKLIST

Have you provided supporting evidence with your application? The checklist below should
help you identify what you need to give us. PLEASE PROVIDE PHOTOCOPIES ONLY.
Please tick one of the boxes next to each item to indicate whether you have provided a
piece of evidence or that it is an income or expenditure that is not applicable to you.

Evidence required                                                  Provided   N/A

Evidence of Tuition Fee Grant and Course Grant: this shows
a breakdown of the grants you receive from Student Finance
England or your Local Authority

NHS Bursary Notification of Award: this shows a breakdown
of the grants you receive within your NHS bursary (students on
NHS courses only)

Tax Credits award notice: if you or your partner are in receipt
of child or working tax credits you need to provide ALL pages of
your most recent HMRC assessment

Benefits: if you or your partner are in receipt of any welfare
benefits you need to provide the assessment letter showing the
weekly award

Earnings: if you or your partner has earnings you will need to
provide either three months payslips or if self employed a tax
return or recent accounts

Childcare costs: to have childcare costs included in the
assessment you must have had the relevant section of this form
completed by your childcare provider and you will need to
provide a birth certificate(s)




                   YOU MUST SIGN THE DECLARATION OVRLEAF




                                                                                          8
DECLARATION

I hereby confirm that the contents of this application are true and correct. I agree that if I
am awarded a payment from the Access to Learning Fund any Emergency Loan that has
been issued to me may be deducted from my payment and I will receive the balance.

I agree that if anything in this application is intentionally misleading:

      The University may take disciplinary and possibly legal action against me and

      I will have to repay any money I have received from the Access to Learning Fund

I agree that if anything on this form changes during the academic year I will inform the
Student Funding Team in writing. I understand that in such circumstances my application
will be reassessed and that I may be expected to repay some of the money which I have
received.

I understand that it is my responsibility to keep the University Finance Department up to
date with my bank account details.

The Student Funding Team is occasionally asked by the University Finance Department to
confirm whether a student has made an application to the Access to Learning Fund. The
team would only confirm if an application has been made and would not disclose any
further details of the request or the outcome. If you would prefer the team to withhold
confirmation that you have made an application please tick this box

I also confirm that to the best of my knowledge I fulfil one of the following criteria
(you must tick one relevant box):

      I am a UK national
      I am an EU national
      There are no restrictions on my stay and I am settled within the UK (I have the right
       of abode in the UK or have Indefinite Leave to Enter/Remain in the UK (ILE/R))
      I have been recognised by the UK government as a refugee and have full refugee
       status/ILE/R in the UK
      I have Exceptional Leave to Enter/Remain in the UK/Humanitarian
       Protection/Discretionary Leave (ELE/R/HP/DL)
      I am an EEA or Swiss migrant worker or the spouse of an EEA or Swiss migrant
       worker      (if so please indicate whether you intend to continue working whilst
       studying) Yes         No
      I am the child of an EEA or Swiss migrant worker
You must also meet the requirement below:

I have been ‘Ordinarily Resident in the UK and Islands for three years immediately before
the start of my course for purposes other than full time education’. Please sign below:

Signed                                   Date




                                                                                                 9
THIS PAGE IS INTENTIONALLY LEFT BLANK




                                        10
BANK DETAILS (THIS PAGE WILL BE DETACHED AND PASSED TO THE FINANCE
DEPARTMENT)

YOUR DETAILS



NAME

ADDRESS




POSTCODE

ENROLMENT NUMBER


DETAILS OF YOUR BANK



NAME OF YOUR BANK



BANK ADDRESS




POSTCODE
BANK SORT CODE                            A/C NUMBER


AUTHORISATION
Please arrange for all future payments to be made by BACS transfer into the bank
account shown above

Name                        Signature                      Date
        IN BLOCK CAPITALS


FINANCE OFFICE USE ONLY

BANK DATA CHECKED BY                             DATE




                                                                                   11

				
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