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					DSA3
change of circumstances

 This document is also available in Welsh. Mae’r ddogfen hon ar gael yn y Gymraeg
 hefyd.

 You can download this form from our website at
 www.dfes.gov.uk/studentsupport/formsandguides/index.shtml and from the Student
 Finance Direct website at www.studentfinancedirect.co.uk


   If your circumstances change at any stage, you must tell your local
   education authority (LEA) immediately so that they can work out if this
   has any effect on your support.
   Please fill in section 1, then sections 2 to 7 as appropriate, and sign
   section 9 and send it to your LEA.
   Please use black ink and CAPITALS only.
   If there are tick boxes, please tick those that apply.




DSA3/V4
     Section 1: To be filled in by all students

1a    ART ID (if you have one)

1b    Student Support
      Number (SSN)
      (if you have one)

 2    Your title

 3    Surname or family name
 4    First name or names

 5    Date of birth                    D   D   M   M   Y   Y   Y   Y




DSA3/V4                                                                1
     Section 2: Change of name

 6   Your title
 7   New surname or new family name
 8   New first name or names
 9   Date of change                            D   D   M   M   Y   Y   Y   Y

10   Brief reason for change (please provide evidence such as a marriage
     certificate, or a deed poll)




DSA3/V4                                                                        2
     Section 3: Change of home address and/or telephone
                number
11   New home address




                                            Postcode
12   New home phone number (including dialling code)



13   Date your home address or phone            D   D   M   M   Y   Y   Y   Y
     number (or both) changed or will change.




DSA3/V4                                                                         3
     Section 4: Change of university or college

14   Name of the university or college where you were studying


15   UCAS university or college code
     (if you know it)

16   Name of the university or college where you will be studying


17   UCAS university or college code
     (if you know it)
18 Is your new course being run under a franchise                           Y   N
   arrangement from another university or college?

     (Do not answer this question unless your new
     course is full time or a part-time course of
     initial teacher training.)

     Please give the name of the main (franchising) university or college



19   Did the transfer take place after starting your course?                Y   N


       If you change your university or college you must also fill in
       section 5.
       Please attach:
          a copy of your new or revised offer; or
          your UCAS form if you have one.




DSA3/V4                                                                             4
     Section 5: Change of course

20   Full title of the course you were studying or were planning on studying (for
     example, MA French Literature)


21   UCAS university or college code
     (if you know it)
22   UCAS campus code (if you know it)

23   Full title of the course you will be studying (for example, MA French
     Literature)


24   UCAS university or college code
     (if you know it)
25   UCAS campus code (if you know it)

26   Date you will start your new course           D   D     M   M   Y   Y   Y    Y

27   Date you will finish your new course          D   D     M   M   Y   Y   Y    Y

28   Is your new course: (Tick one box only.)       full time?       part time?

29   Length of new course in years
30   What year of the course are you
     entering (for example,1, 2, foundation)?
31   Will your term address be: (Tick one box only.)

      halls of residence?        private accommodation?          with parents?

32   New term time address (if you know it)




                                                  Postcode

33   Is this change a result of a transfer after starting your course?       Y    N



DSA3/V4                                                                               5
     Section 6: Leaving your course or suspending your
                study

34   Date you left or suspended your studies      D    D   M   M    Y    Y   Y   Y


35   Do you plan to return to higher education?
      Y               When will you return?       D    D   M   M    Y    Y   Y   Y

      N


36   Do you plan to return to:

      the same course?

      a different course?           Please ensure that you have completed
                                    Section 5.

37   If you plan to return, will you be repeating any period of study?
      Y               What period will be repeated?
      N

38   Please give the reason for leaving your course or suspending your
     studies.




39   Have you told your university or college that you have left your course?
                                                                             Y   N



DSA3/V4                                                                              6
     Section 7: Other changes

40   Please enter here any other changes which are not covered by this form.




DSA3/V4                                                                        7
   Section 8: Data Protection Act 1998

    The following statement describes who will use the information provided on
    this form and what they will use it for.

    We will use the information which you or your university or college give on
    this form to process your application for Disabled Student Allowances
    (DSAs). The Secretary of State for Education and Skills has transferred
    certain functions relating to your student support application to local
    education authorities (LEAs) and to higher education institutions
    (colleges and universities). The Student Loans Company (SLC) also carries
    out certain functions on his behalf.

    Your local education authority needs the information you provide on this
    form to work out whether you are eligible for DSAs and assess the
    maximum amount of support you are entitled to. It is the data controller for
    that information. Your LEA will make the results of this assessment
    available to the SLC so they know how much to pay you. Your LEA will, with
    your consent, pass the information you have provided on this form about
    your disability or specific learning difficulty to the disability adviser at your
    university or college or your DSA assessor (or both), where this is
    necessary to make sure you get the support you need. Your LEA will keep
    your personal information so they can audit their assessment of student
    support. If you would like to see your information, please contact your LEA.

    The Student Loans Company needs the information you provide on this
    form to process your application for DSAs and handle the payments and
    recovery as appropriate. It is the data controller for that information. The
    SLC will have to keep personal information about you for these
    purposes. The Department for Education and Skills is also a data
    controller for this information as it is responsible for it by law. However, if
    you would like to see your information, please contact the SLC. The SLC
    may use your information to maintain or develop their systems.

    LEAs and the SLC will have shared access to your account information to
    provide customer assistance services to you and, generally, to
    respond to your questions and update information on your account.




DSA3/V4                                                                                 8
   Section 8: Data Protection Act 1998 (continued)

    Your college or university will receive information from the SLC so they
    can pay your DSAs. Your college or university may have shared access to
    your application and account information in the future to help them do this.

    The Department for Education and Skills may use the information you
    have provided on this form to monitor the performance of the student
    support system and to develop future policy. Any published output from this
    statistical work will be anonymous and will not identify individuals.

    By law, your LEA, the SLC and your college or university must protect the
    public funds they handle and may use the information you have
    provided on this form to prevent and detect fraud. They may also share the
    information, for the same purposes, with other organisations which handle
    public funds.




DSA3/V4                                                                            9
   Section 9: Declaration - to be signed by all students

      I declare that as far as I know, the information I have given in this form
      is correct.
      I will write to the LEA immediately about any changes in my
      circumstances which may affect my eligibility or entitlement to support.



    Signature                                  Date
                                                D     D   M   M   Y   Y   Y    Y



    Please return this form to your local education authority.




DSA3/V4                                                                            10
DSA3/V4   11