Sir John Deane’s College
16 -19 Bursary Fund and/or Free College meals
Application Form 2015/16
PART A – Student’s Details
Full name:
Tutor Group (if known)
Address
Home telephone :
Mobile:
Email
Date of Birth
Are you living at home with parent(s) / guardian(s) / carer(s)?
If you answered yes please complete Part B and Part C
Do you receive both, Disability Living Allowance and Employment
Support Allowance or Employment Support Allowance and a
Personal Independence Payment?
If you answered yes, please complete Part B and Part C
Are you living entirely independently and claiming benefits?
If you answered yes, please complete Part C only
Yes
No
Yes
No
Yes
No
Are you living in care, or a Care Leaver?
Yes
No
Do you wish to apply for a Free College Meal?
Please see guidance notes for eligibility criteria.
Yes
No
Financial Support Requested from 16-19 Bursary
We can only provide financial support for costs associated with attending college. This can include things
like assistance with the cost of travel to and from college, lunches whilst at college (if you do not qualify
for Free College Meals), books, printing and materials for your courses, educational visits, exam re-sit
fees etc. Please use the boxes below to let us know what would help you most. (Further information on
estimated costs is included in the guidance notes)
Assistance requested
(Estimated cost)
Transport - If using a bus or train, please specify which
route and give cost for the year (if known):
Route:
If using Arriva buses, would you like the College to buy
your bus pass? Yes / No (please circle)
Lunches (if you do not qualify for Free College Meals)
Educational visits ( You don’t need to specify an amount)
Leave blank
Exam re-sits ( You don’t need to specify an amount)
Leave blank
Other- e.g books, printing, stationery -please specify.
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Priority
(1, 2, 3 etc).
PART B -To be completed by the parent(s) / carer(s)
Parent/carer
Parent/carer
Please state relationship to the
student
First name
Surname
Address
Post code
Home telephone
Mobile telephone
E-mail address
PART C – Your Total taxable household income
Please provide copies of official evidence or bank statements to support the
information that you enter in the table below.
Type of Income
Total taxable household income for all parents / carers
(Please enter total household income and provide
evidence)
Gross salary/s –( latest 3 payslips
required or P60, or Tax credit
award notice)
Income from self employment –
latest accounts / tax return
Pensions
Investment income e.g. dividends /
bank interest
Taxable benefits
Other taxable income (give details)
Eligibility for Free College Meals
depends on receipt of the
following:
Income Support
Please enter amounts below and provide evidence.
Ideally the Tax Credit award notice.
Income based Job Seekers’
Allowance
Income related Employment and
Support Allowance (ESA)
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Support under part VI of the
Immigration and Asylum Act 1999
Guarantee element of State
Pension Credit
Child Tax Credit and have a gross
annual income of up to £16,190
Universal Credit
Student’s Bank Details
Payments will normally be made directly into the student’s bank account.
Account Name
Name of bank / building society
Sort code
Account number
DECLARATION (Please ensure the form is signed)
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I / we have read and understood the guidance notes supplied with this application form.
I / we confirm that the information given above is correct and complete to the best of my / our
knowledge and belief and is a true reflection of my / our financial position.
I / we undertake to inform the College immediately if my / our circumstances change.
I / we understand that if the student leaves College he / she will not be eligible to receive
further payments and any overpayments may have to be repaid.
I / we understand that payment of any bursary award is conditional upon the student meeting
his / her obligations under the College Commitment regarding attendance, performance,
behaviour and compliance with all College procedures.
I / we understand that the information provided may be shared with other agencies or
organisations, as allowed by law, for the purposes of checking this application and / or the
prevention of fraud.
I / we confirm that the student is eligible for support from the 16-19 Bursary Fund on
residency grounds and will provide suitable supporting evidence if required.
I / we understand that giving false or incomplete information which results in an overpayment
will mean that the College will stop any future payments, and seek repayment of anything paid
so far. The matter may also be referred to the police with the possibility of the student and/or
their family facing prosecution.
Signed by the
student
Date
Signed by Parent /
Carer
Date
Signed by Parent /
Carer
Finance Use only: Date received
Date
Finance Use Only: Bursary- Date Approved
Finance Use Only: FCM – Date Approved
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