FAMILYNAME ID
Financial Assistance Service
Student Services Unit
PO Box 123 Broadway, NSW 2007
(Level 6, Tower Building)
Ph: 02 9514 1177
Fax: 02 9514 1172
Email:
financial.assistance@uts.edu.au
YYYY MM DD EG
TTY: 02 9514 1164
UTS Student Equity Grant Application 2015
The Student Services Unit has established a Student Equity Grant fund to provide assistance
to students experiencing financial hardship.
General Information

Grants will be allocated based on the assessed level of financial hardship and its effect
on academic outcomes. Applicants will be experiencing either sustained or temporary
financial hardship.

It is anticipated that Grants will assist with the cost of course related expenses
(excluding the UTS tuition fee or the student amenities fee) and/or with short-term
living costs which are necessary for you to continue your studies.

Grants are not intended as an alternative to other forms of income.

Applications for up to $500 will be considered.

You must complete all sections of the form clearly before your application can be
processed.
Eligibility

Applicants must be currently enrolled in an award courses at UTS or with the Unistart
Program. Applicants must be Australian Citizens, permanent residents, or holders of a
permanent humanitarian visa.

Students on Leave of Absence or facing Exclusion are not eligible.
students, Non-award students or Insearch students are not eligible.

Applicants will likely be receiving a Centrelink benefit or be able to demonstrate
exceptional financial hardship.

Recipients of a Commonwealth Equity Scholarship, a Start-Up Scholarship/Loan, or UTS
Diversity Access Scholarship may still be eligible for a Student Equity Grant, depending
on demonstrated need for additional course related expenses or exceptional financial
circumstances.
International
Application Process

Complete the application form before your appointment.

Make an appointment with Financial Assistance by calling (02) 95141177 or via email:
Student.Services@uts.edu.au if phone is not accessible for you.
Attach or bring supporting documents to your appointment:

A copy of all current bank statement/s with transaction history (PDF format) of the past
8 to 12 weeks

Evidence of rental payments/lease (where relevant)

Any relevant bills and debts and extra-ordinary costs which support your request.

Include any other evidence of income (for example: three recent payslips or a Tax
Assessment Notice).
EQUITY GRANT APPLICATION 2015
Family Name: ___________________________
Student ID: __ __ __ __ __ __ __ __
Given Name: ___________________________
D.O.B: __/__/____ Gender:
Citizenship: Tick a box to select the status that is relevant to you.
Australian Citizen Permanent Resident Permanent Humanitarian
Other Status:
____________
Admission: If you entered UTS under an admissions program please tick a box to indicate which one
InpUTS/PRS
Special Admissions
Access Scheme
Scheme
Jumbunna Indigenous House of Learning’s
Alternative Admissions Program
 none of these
Special Needs Registration:
Are you a student registered with the UTS Special Needs Service?  YES
 NO
If yes, please indicate who your Disability Services Officer is: Liz Penny
Evan Knowles
Nicola Tait
Kimberley Cheung
Claire Edwards ________________
Study Details:
Undergraduate
Post Graduate
Faculty: ______________________ Course: ____________________________________________
* (non-award or Insearch students are not eligible)
When did you start your course? Year: __ __ __ __
Autumn
Spring
When do you expect to complete your course? Year: __ __ __ __
Autumn
Spring
Practical Experience Course Requirements:
Are you completing a clinical placement, professional experience, major/industry project or
internship this year? yes no
If yes, how many weeks? ______ in Autumn ______ in Spring and/or Summer semester _______
Fees:
How did you/will you pay your fees this semester?
 Deferred payment by HECS-HELP or FEE- HELP Parents
Self
Employer Other
(OFFICE USE ONLY)
SEG No. 15
DATE APP
____ /____ /15
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Grant Amount $
FAMILYNAME ID
YYYY MM DD EG
Personal and financial details
Marital status:
 single
married/partnered
other
 yes
Do you have other people who are dependent on your income?
 no
If yes, please state the age of the dependent(s) and their relationship to you:
______________________________
 yes
Do your parents/partner/other assist you financially?
If yes, give details:
 no
________________________________________________________
________________________________________________________
Your financial position today:
Bank balance
Cash (on hand)
Other
$_________
$_________
$_________
Bank loan
Credit Card(s)
Personal Debts
Other:
TOTAL AVAILABLE FUNDS: $_________
$__________
$__________
$__________
$__________
TOTAL CURRENT DEBTS $__________
Estimated Annual Income
Income
Fortnightly
Yearly
Employment 1 (PT / FT/Casual)
net $________ x26 =
$_________
Employment 2 (PT / FT/Casual)
net $________ x26 =
$_________
Partners Income
net $________ x26 =
$_________
Allowance from Parents/other
net $________ x26 =
$_________
Centrelink Income
net $________ x26 =
$_________
Centrelink CRN: _____________________________ Name CL benefit: _______________________
Scholarships/grants eg: DAS, Start up, Relocation, APA
(Please specify ALL) _______________________________
Other Income e.g rental, shares, interest,
workers compensation (please specify) _______________
TOTAL ESTIMATED INCOME – ANNUAL
net $________ x26 or
$_________
$_________
$_________
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FAMILYNAME ID
YYYY MM DD EG
Estimated Annual Expenses
Expenses
Fortnightly Costs
Yearly Costs
Rent/Mortgage/Board (please circle)
$________x26= $___________
Food supplies and groceries
$________x26= $___________
Travel (Bus/Train $___+Petrol $___+Semester Breaks $___) $________x26= $___________
Entertainment (inc coffees, Uni lunches, drinks etc ….)
$________ x26= $___________
Other accommodation expenses (e.g Bond, Furniture, Rates)
$___________
Mobile Phone/internet/Home Phone
$_______x 12 (monthly)
$___________
Gas, Electricity House insurance
$_______x 4 (quarterly)
$___________
Dependents: Including Childcare costs
(Include costs related to caring for dependents e.g. uniforms, activities, transport, school fees,
medical etc.)
$___________
Personal expenses, (e.g. haircuts, clothing, gifts etc.)
$___________
Sports / Hobbies / Gym
$________ x26= $___________
Health Fund, Medical/Dental/Medication/other Med costs $________ x26=
$___________
Extra-ordinary medical procedure and treatment costs
$___________
Vehicle Costs (rego$____, insurance $_____, repairs$_____)
$___________
Course materials
(Books, stationary, equipment, computer, photocopying, uniforms etc.)
$___________
Repayment for Credit cards, bank loans, personal debts etc. – please specify:
1.___________________________________________
$________ x26=
$_________
2.___________________________________________
$________ x26=
$_________
3.___________________________________________
$________ x26=
$_________
TOTAL ANITICIPATED EXPENSES – ANNUAL
$_________
Total estimated Income
$_________
Total estimated Expenses
$_________
Balance: Income less Expenses
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$_________
FAMILYNAME ID
YYYY MM DD EG
STUDENT EQUITY GRANT APPLICATION 2015 cont…
What is your primary source of income? _________________________________________
Please provide details (e.g. where you work) ______________________________________
___________________________________________________________________________
Have you received an Equity Grant before?  yes
no
If yes, when was it? _____________________
How did this grant assist you?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Did you or will you receive a scholarship in 2014? yes
no
If yes, which scholarship(s)? (e.g. Relocation, Start-up, DAS, Merit, APA, RTA…)
___________________________________________________________________________
How has/will this scholarship be used to meet your needs?_________________________
___________________________________________________________________________
___________________________________________________________________________
Exceptional Financial Hardship
Only complete this section if you do NOT receive Centrelink income support:
Explain why you are not eligible for a Centrelink income support payment in 2015
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
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FAMILYNAME ID
YYYY MM DD EG
STUDENT EQUITY GRANT APPLICATION 2015 cont…
1. Please outline the reason for your application and provide estimated costs.
Include any additional factors that you would like considered.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
2. Are these expenses unexpected or unusual?  yes
 no
3. What steps have you undertaken to increase your income? E.g. Employment.
Are there any factors impacting on your ability to work? (E.g. Amount of face to face
hours each week required for your course)
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
4. How much are you able to contribute towards your estimated costs?
$_________
5. What is your requested Grant amount?
$_________
Applicant Declaration:
I, (Full Name) _________ ___________________ hereby request financial assistance in the form of
a Student Equity Grant, which will be used to assist me in the furthering of my academic career.
I confirm that I am currently enrolled in an award course at UTS and am not facing Exclusion or
taking Leave of Absence.
I declare that I have completed this form in good faith and to the best of my ability, and that the
information I have provided includes all my current savings and investments, as well as a reasonable
estimate of my income and expenses for the current calendar year. I understand that the
information provided will be used by the Financial Assistance Service to assess my application and
that there may be penalties for deliberately giving false or misleading information.
Student Signature: ____________________________________________
Checklist:
Date: __ / __ / ____
 Completed and signed application
 Attached bank statement/s with transaction history (PDF format) for the past 8-12 weeks
 Attached other relevant documents
OFFICE USE ONLY
Recommended: yes
no
_______FA (interviewer) $__________
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Date: __ / __ / _____
FAMILYNAME ID
YYYY MM DD EG
Please complete this page – if you are currently receiving a Centrelink Benefit
Financial Assistance Service - Student Services Unit
PO Box 123 Broadway, NSW 2007
Ph: 02 9514 1177
Fax: 02 9514 1172
TTY: 02 9514 1164
Email:
financial.assistance@uts.edu.au
University of Technology Sydney (UTS), Financial Assistance Service
Student Consent Form
for Centrelink Income Confirmation
This consent will be used for the sole purpose of authorising Centrelink to provide information to UTS
Financial Assistance Service to assess your eligibility in relation to concessions or services provided by UTS
Financial Assistance Service.
Income Confirmation
I, (your name) _________________________________________DOB:____________________________
UTS Course:_________________________
Student ID:______________________________________
authorise Centrelink to electronically provide a statement of information to UTS Financial Assistance
Services to assist in the assessment of my entitlement to services from UTS Financial Assistance Service. I
understand that the information provided by Centrelink may include, where relevant, current or historical
details of payments received, dependants, Centrelink deductions, income, assets and confirmation of my
current address.
I understand that this authority, once signed, is effective only for the period I am a student of University of
Technology Sydney. I understand that this authority, which is ongoing, can be revoked at any time by giving
notice to UTS Financial Assistance Service.
I understand that I will be able to obtain a written copy of the Statements at any time from either UTS
Financial Assistance Service or Centrelink.
A brochure is available from Centrelink that provides more details about the Centrelink Confirmation eServices or on
Centrelink’s website at www.humanservices.gov.au/
My Centrelink Reference Number (CRN) is:
Signed: ...............................................................
UTS SSU_CL Consent 2015
Dated: .........................................
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Financial Assistance Service
Student Services Unit
PO Box 123 Broadway, NSW 2007
(Level 6, Tower Building)
Ph: 02 9514 1177
Fax: 02 9514 1172
Email:
financial.assistance@uts.edu.au
TTY: 02 9514 1164
AUTHORITY FOR DIRECT PAYMENT OF UTS EQUITY GRANT
FULL NAME
First/Given name
Family name / Surname
ADDRESS
POSTCODE __ __ __ __ __
EMAIL (UTS email)
@student.uts.edu.au
PHONE/MOBILE
STUDENT NO
ACCOUNT DETAILS
Name on Account
_______________________________________________________________ (Account Holder)
Name of Financial Institution
Branch Name
BSB Number (must be 6 digits)
___ ___ ___ ___ ___ ___
Account Number
I accept financial assistance which will be used to assist in the furthering of my academic career.
I understand that UTS does not take any responsibility for incorrect account information supplied.
Signed :
Date ___/___/_____________
(OFFICE USE ONLY)
STUDENT EQUITY GRANT
A/c to be debited:
02.624075.120.0262018.72850.00000.00
Grant Number
SEG 15 ____ ____ ____
Grant Amount $ ____________•00 is approved
Signed :
Date ____ /___ / 15
Name: Brett Smout/Claire Edwards
Authorisation delegation for Equity Grants
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