PART-TIME STAFFORDSHIRE UNIVERSITY BURSARY SCHEME
APPLICATION FORM 2015/2016
Applications must be submitted together with all documentary evidence not later than 1 April 2016.
Personal Details:
Title:
Forename:
Surname:
Student ID No:
Date of Birth:
Student Support No (if applicable):
/
/
(dd/mm/yy)
Address:
Postcode:
Email Address:
Phone/Mobile:
Country of Domicile:
Are you ordinarily resident in England?
Yes/No* (delete as appropriate)
*The bursary is not available to a student who is ordinarily resident in Scotland, Wales or Northern Ireland.
Course of Study:
Year of Study:
Length of Course:
How many credits are your studying in 2015/2016 academic year:
HOUSEHOLD INCOME STATEMENT
JF/Jan2013
What is Household Income?
Your household income is the total amount your family earns each year before tax and national insurance.
Dependent Students – If you are a dependent student your income and your parents’ income is assessed.
You are classed as a dependent student unless one or more of the bullet points below applies. If you believe
you are an independent student please tick the relevent box(es) below.
Independent Students - If you are an independent student your income and your partner’s income (if
applicable) is assessed. You are classed as an independent student if:
You are 25 years old or older
You are or have been married or in a civil partnership
You have a dependent child
You have supported yourself for 3 years
You have no living parents
You are estranged from your parents
What is your current Household Income: £
You must attach copies of documentary evidence for each relevant item in the table below to your
application or we will not be able to process your application.
Please supply evidence of household income e.g., Earnings (P60, P45 or wage slips) OR evidence of benefits
(Working Tax Credit, Job Seekers Allowance, Housing Benefit, Income Support, Incapacity Benefit/ESA).
The evidence of any current income or benefits must be no more than 3 months older than the date of your
NSP application.
Fill in either weekly, monthly or annual figures only in the table below for you and your parent (if applicable)
or partner (if applicable) as appropriate:
Your Income
Weekly
Wages/Salary
Child Tax Credit
Working Tax Credit
Job Seekers Allowance
Income Support
Incapacity Benefit/ESA
Council Tax Benefit
Housing Benefit
Other Income (Please
specify)
JF/Jan2013
Monthly
Parent/Partner Income
Annually
Weekly
Monthly
Annually
DECLARATION



I certify that the information that I have given in this application is true and correct to the best of
my belief.
I understand that giving false information will automatically disqualify my application and may
also lead to disciplinary procedures resulting in possible exclusion from the University
I understand that I must provide documentary evidence as requested. I agree that relevant third
parties may be contacted by University staff in connection with this application and that
information I have provided in this application may be disclosed to those parties for the purpose
of verification or clarification. I will not unreasonably refuse to grant permission to a third party
to disclose relevant information to the University if a third party requests such permission. I
understand that my failure to grant such permission without good reason may result in the
University being unable to process my application for financial support.
Name (capitals):
Signature:
Date:
I also agree to repay the whole amount of any payment made to me as a result of this application if the
information I have entered on this form is shown to be false in any way:
Signature:
Date:
Once you have fully completed this form please hand it together with all supporting documents to:
Information Centre
Cadman Building
College Road
Stoke on Trent
ST4 2DE
OR
Information Centre
Beaconside
Stafford
ST18 0AD
Please do not include originals of documents.
Please note that a decision will not be made until all relevant documentation has been received. Applicants
will be informed of decisions via their University email account.
JF/Jan2013