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Office Use Only Stamp application received
PG
Logged in SSiD ……………..
Reg Status ......................
Expected End ......................
Missing Documents: YES/NO (if yes state below)
Application for Financial Support 2007/2008
( Access To Learning Funds and University Hardship Funds)
STUDENTS REGISTERED ON FULL TIME AND PART TIME POSTGRADUATE
COURSES (NOT PGCE)
If you are a European or International Student this is not the correct form, you need the application
form for International Students. Please ask SSiD staff for the correct form.
MONITORING
To enable us to improve our publicity for the financial support scheme, please state where you
first heard about the existence of support schemes (Please circle one box only):
Word of Mouth Advice Centre University Poster
University Web Pages Other Web Pages University Leaflet/Booklet
Hall Staff/Community Assistant
Other (please specify)……………………………………………………………………
Section A – PERSONAL DETAILS
1. Student Registration Number: .......................................................................................
2. Your Title (please circle) Mr Mrs Miss Ms Other (Please State)............
3. Your first names (in full) .......................................................................................
4. Your Family Name (in full) .......................................................................................
5. Address:- Please ensure that the University has your most up-to-date address. Check this using
“Your University Record” on the Current Students web page: www.shef.ac.uk/ssid/record
* Please give a correspondence address to be used during vacation periods if different
from term time address:
Term Time Correspondence
6. Telephone number (Include area code):
Term time.................................... Home.................................... Mobile.............................................
7. University Email Address ............................................................................................................
(Please check your email and keep it updated on a regular basis, we may wish to contact you for
additional information to support your application or with up to date announcements)
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Section A – PERSONAL DETAILS Continued
8. Date of Birth …… / …… / ……
9. Your age (in years) on 1/9/2007 ....................................
10. Nationality ....................................
11. Marital Status (please circle)
Single Married Divorced Living with Partner
Other (Please State) ............................
12. Sheffield accommodation - Do you live (please circle)
i) alone ii) with Partner/Spouse
iii) with Parents/Guardian iv) in shared accommodation
Please give details of everyone sharing the accommodation (include your partner, any
children and other members of your family where applicable).
Name Relationship to you e.g. friend, parent
Section B - COURSE DETAILS
13. As an Undergraduate Student were you fully funded by your LEA? (Local Education Authority)
e.g. Tuition Fees Paid in Full and Full Student Loan/Grant (please circle) Yes No
14. Course Title .........................................................................
15. Faculty/Department .........................................................................
Graduate (please circle) MA MSc MPhil PhD
16. Are you studying (please circle) Full time Part time
17. Date of START of Course ...... / ...... / ...... Please give details if you have changed
course/repeated a year/taken a year out:-
.............................................................................................................................................
18. Year of Course (please circle) 1 2 3 4 5 6 7
19. Is this a repeat year? (please circle) Yes No
20. Is this your final year? (please circle) Yes No
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Section C - YOUR DEPENDANTS
21. Do you have any children who are financially dependent on you? Yes No
If yes please give details:- (please circle)
Full Name Date of Birth Age Do they live with you?
If you need to, continue on a separate sheet and attach it to this form
Evidence included
22.Do you have any adults who are financially dependent on you? Yes No
If yes please give details:- (please circle)
Full Name Date of Birth Do they live with you?
If you need to, continue on a separate sheet and attach it to this form
Section D - DISABILITY / SPECIAL MEDICAL NEEDS
23. Do you have a disability, chronic or long term illness? Yes No
(please circle)
If Yes, what is the nature of your condition? ..........................................................
......................................................................................................................................
......................................................................................................................................
Evidence included
24. Have you applied for Disability Students’ Allowance (DSA)? Yes No
(please circle)
If Yes, do you receive an amount per week? £.......................
Evidence included
Section E - DEBTS TO THE UNIVERSITY
25. Do you have any of the following debts to the University (NOT Tuition Fees) and, if so
what is the amount owed?
i) University Accommodation YES/NO Amount £ ..................
ii) Short-Term University Loans YES/NO Amount £ ..................
If you are made an award, would you be willing for the University to pay off the above debts from
your award? YES/NO*.
Please circle how much a) 100% b) 75% c) 50%
You should be aware that you will not be eligible to graduate if you have a debt with the
University.
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Section F - INCOME & EXPENDITURE
Please specify your main source(s) of income and amount per year.
Please Note that our assessment will assume the income, declared and agreed, on your
Financial Guarantee Form.
(over 52 weeks) INCOME £ per week EXPENDITURE £ per week
SELF PARTNER SELF & PARTNER
Scholarship Tuition Fees
£…………. £…………. £………….
Rent / Mortgage
(please specify) ______________________ * we only consider the annual £………….
interest element of your mortgage
Bursary Utilities and Food
£…………. £…………. £………….
Parental/ Fees Childcare Costs
£…………. £…………. £………….
Partner
Other
contribution £…………. £………….
Sponsorship Travel costs
£…………. £…………. (home to university)
£………….
Child Maintenance Travel costs
£…………. £…………. £………….
(placement travel)
Other Income Number of placement
£…………. £………….
weeks
Private vehicle costs
(please specify) ______________________ £………….
A) Insurance
Disabled Students’ B) MOT/Service/Tax
£…………. £…………. £………….
Allowance
Professional/ Career C) Fuel
£…………. £…………. £………….
Development Loan
Employment Income
£…………. £…………. Other costs £………….
(please specify)_______________________
Income Support TOTAL
£…………. £…………. £
Housing/ Council
£…………. £………….
Tax Benefit
Jobseekers’
£…………. £………….
Allowance
Working Tax Credit
£…………. £………….
Child Benefit
£…………. £………….
Child Tax Credit
£…………. £………….
Disability Benefits
£…………. £………….
(please specify) ______________________
Pension
£…………. £………….
TOTAL £ £
Evidence of ALL income & expenditure included
Please refer to our web budget planner for guidance: www.sheffield.ac.uk/budgetplanner
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Section G - SUPPORTING STATEMENT
26. It is compulsory to complete this section.
This section is your opportunity to describe your circumstances in detail including
unusual “one-off” costs that could not have been foreseen, or if you have experienced
exceptional circumstances that have affected your financial position. You should also use
this space to explain why it is not possible for you to engage in paid employment, stating
why you are in financial difficulty, and why you believe your situation to be exceptional, to
merit additional support. (This does not have to be in essay format, please feel free to write
brief notes and use bullet points).
(You may continue on a separate sheet if necessary).
Remember to support your statement with documentary evidence
(see examples at the bottom of the page)
Evidence: Proof of any short-term illness/medical condition/burglary or any other evidence relating
to special circumstances mentioned in this section etc. (i.e. doctor’s note, police report, death
certificate, travel receipts)
Evidence included
If you need to continue, then do so on a separate sheet and attach it to this form
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Section H – BANK & BUILDING SOCIETY
27. Please give below details of ALL accounts held by you and your partner in banks,
building societies, financial institutions etc
Bank/Building Society etc. Branch where account held Account No.
28. Do you have any savings / Premium Bonds? Yes No (please circle)
If Yes how much ? £........................... Evidence included
29. Have you arranged an authorised overdraft with your bank?
Yes No (please circle) If Yes what is the limit of the overdraft ? £..................
Evidence Required: Photocopies of EACH account you and your partner hold of the latest
three months consecutive bank statements/bank ledgers listing transactions, a copy of Building
Society Books and 3 months’ credit card statements.
Evidence included
30. Do you have any of the following monthly repayments?
£
Court Fines
Council Tax
Debts to Utility Companies (current address only)
HP Agreements/Rentals
Personal Loans
Other (please specify)
Evidence included
31. Please provide an explanation of any regular transactions listed on your statements
e.g. parental contribution/mobile phone bills, and any debits or credits over £100 that
appear on your statements.
Name of Date of Amount £ Explanation Paid Paid
Account Transaction In Out
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Section I - CHECKLIST OF EVIDENCE REQUIRED
As part of your application you need to provide PHOTOCOPIES of the following documents
(where applicable). All relevant proof MUST be enclosed to make your application complete.
Incomplete applications will not be considered. All proof must include amounts of money
payable. Please tick the box of all relevant evidence enclosed.
1) Scholarship Offer Letter
2) Bursary Offer Letter
3) Sponsorship Offer Letter
4) Letter supporting income from other source
5) Evidence of your part time earnings (where applicable) ie. last 4 weeks wage
slips or last applicable payslips.
6) Evidence of your partners’ income (where applicable) eg. Grant or award, three
months pay slips, benefit awards/entitlements etc.
7) Proof of Accommodation costs. eg Rent Agreement or proof of mortgage
INTEREST payments: a certificate showing this can be obtained from your
Bank/Building Society. Also include evidence of any Buildings Insurance.
8) Inland Revenue notification of Child Tax Credit and/or Working Tax Credit
awards.
9) Evidence relating to travel and/or private vehicle costs.
10) Evidence of Council Tax Payments (where applicable)
11) Proof of your financial situation - at least 3 months’ most recent consecutive up
to date bank statements/ bank ledgers listing transactions for EACH account you
and your partner hold, a copy of your Building Society Book, 3 months’ credit card
statements etc. These statements must show your/ your partners name and bank
details – mini statements are not acceptable.
12) Evidence of benefits.
13) Evidence relating to special circumstances in Section G.
14) Evidence relating to disability declared on your application.
15) Evidence relating to childcare costs declared on your application.
CONFIDENTIALITY
Applications are seen only by Student Services staff and the Financial Help Advisory
Panel. It may be necessary for additional supporting evidence to be sought by
yourself from other university staff in order for the Panel to reach a decision.
Please turn over the page and complete the declaration.
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Section J - ETHNIC BACKGROUND
This section is for monitoring purposes only and is NOT compulsory
Please tick as appropriate
Asian Other Chinese
Bangladeshi Indian
Black African Other
Black Caribbean Pakistani
Black Other White
DATA PROTECTION ACT 1998
The University of Sheffield is a data controller in terms of the 1998 legislation. The
Student Services Department 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 third party without your consent, except when the
University is required to do so by law. Should you have any concerns as to how this
information is used please contact the Student Services information Desk in the
Union of Students.
DECLARATION AND SIGNATURE
♦ I have read all the documentation included with this application.
♦ I declare that the information I have given on this form is true, complete and
accurate.
♦ I understand that providing false information in an attempt to obtain funds from
the University, DfES or other funding body would be fraudulent and could result
in disciplinary action and will automatically disqualify my application.
♦ I have fully declared all financial accounts I and my partner, if relevant, hold and
all sources of income.
♦ I will contact the University if my circumstances change in any way.
♦ I have enclosed documentary evidence in support of my application and
understand that my application will not be processed without adequate
evidence.
Signature………….........………………….............. Date…………………………………
RETURN TO: SSID DESK IN THE UNION OF STUDENTS BUILDING, WESTERN BANK,
SHEFFIELD, S10 2TG, MONDAY - FRIDAY before 4.30 pm
PLEASE NOTE: THE ASSESSMENT PROCESS IS MADE BY THE FINANCIAL APPLICATION SUPPORT TEAM AND NOT SSiD.
m:\sd_share\Financial Support\FINSUPPO\FINSUPSC\STANDARDDOC\2005/06\ALF PGApplication Form Aug 2006
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