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Bexley hardship fund application form
Bexley hardship fund application form
Bexley hardship fund application form
Bexley hardship fund application form
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Bexley hardship fund application form

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  • 1. Page 4 - Additional BACS Form BexdLS10-11 discretionary Learner Support (dLS) Application Form for 16-18 year olds studying in Schools in the 2010/11 Academic Year ACCOUNT DETAILS FOR PAYMENT Discretionary Learner Support payments will be made from the London Borough of Bexley into abank or building society account. It is expected that any payments will be made in to the student’s bank/building society account. Only by exception will a payment be made into another account and the reasons for this will need to be stated below.A1) DETAILS FOR PAYMENT – STUDENT DETAILSName of StudentAddressBank/BuildingSociety Accountis registered to PostcodeA2) DETAILS FOR PAYMENT – ACCOUNT DETAILSName of Bank/Building SocietyAccount NumberSort Code - -Building Society Roll NumberAccount Holders Name (Block Capitals please)This should be your name as it appears on your cash statementsIf the payment is not to be made into the student’s account please explain where the payment isbeing made and whyA3) DETAILS FOR PAYMENT - DECLARATIONI can confirm that the details contained on this form are correct and that I authorise the LondonBorough of Bexley to check on validity of this information and to use my Account details tomake the discretionary Learner Support paymentNameSignature DatePlease return the completed form to:Claire Ellis, 14-19 Manager, Education and Social Care, London Borough of Bexley, Hillview,Hillview Drive, Welling, DA16 3RYIf you have any queries please contact Claire Ellis on 0203 045 4222 or claire.ellis@bexley.gov.ukFOR OFFICE London Borough of Bexley Authorisation to pay:USE ONLY LA Budget Code Amount £Name Signature Date
  • 2. Page 1 BexdLS10-11 discretionary Learner Support (dLS) Application Form for 16-18 year olds studying in Schools in the 2010/11 Academic Year Please read the policy notes before completing this application form1) PERSONAL & CONTACT DETAILS FOR STUDENT (please print clearly)First Name SurnameHome Address PostcodeDate of Birth E-mailDay time telephone number2) COURSE & SCHOOL DETAILS (please print clearly)School attendingFull details of course(s) beingstudiedDate course(s) started3) DETAILS OF SPECIFIC HARDSHIP NEED (Please print clearly) Please tick relevant box(es) Estimated CostSpecial Equipment £Books £Materials £Essential Course Trip £UK University/College interview expenses £Temporary Travel Costs £Assistance with domestic emergency £Short-term emergency accommodation £Costs of re-sitting exams £Other specific hardship (please explain in £box below)Please explain below why you are applying for the above AND how you have reachedthe estimated costs included
  • 3. Page 2 BexdLS10-114) PROOF OF ELIGIBILITY FOR APPLICATION (Please print clearly)Please tick ONE of the below and include your evidence with your application Student currently receiving EMA Please provide – a copy of your EMA Notice (£10, £20, or £30 weekly of Entitlement or other correspondence fromA allowance) in the 2010/11 the Learner Support Service proving you are Academic Year receiving EMA Parents/Carer’s household income Please provide – a copy of a recent Tax is below £30,810 in 2009-10 Credit Award Notice or other evidence (e.g.B and/or 2010-11 financial year P60) from the Tax Office of the household annual income Parent(s)/Carer(s) (or Student* if Please provide – a copy of recent independent) are receiving welfare correspondence or other written documents benefits from the Benefit Agency confirming parent/carer/student is on benefits (* pleaseB note that if a student is in receipt of benefits receiving dLS can affect benefit amounts, please contact Job Centre Plus Benefit Claims helpline on 0800 055 6688) Student is currently eligible for Please ask a relevant member of staff atD Free School Meals your school to complete the statement at 4.2 Student is currently in care or Please ask your Connexions Advisor orE leaving care Social Worker to complete the statement at 4.2 Student is currently on probation Please ask a relevant member of staff fromF the Youth Offending Team or Probation to complete the statement at 4.2 Student is a young parent Please ask your Connexions Advisor orG Social Worker to complete the statement at 4.2 Student has not yet achieved 5 Please ask a relevant member of staff atH GCSEs A*- C including Maths & your school to complete the statement at English 4.2 Student has a disability and/or Please ask your Connexions Advisor toI learning difficulty complete the statement at 4.2 Student is studying English as a Please ask a relevant member of staff atJ second language your school to complete the statement at 4.2 Any other special financial Please state below your other financial circumstance not covered by the circumstance and details of evidence you above, but which can be will supply evidencedK
  • 4. Page 3 BexdLS10-114.2) ADDITIONAL STATEMENT (where applicable for proof of eligibility)Student Name Delete as appropriate:I am the SOCIAL WORKER / TEACHER / CONNEXIONS ADVISORstudent’s If other please state: My day timeMy name is contact numberMy e-mail For example that the student is a parent etc (please see section 4)I am signing toconfirm the followingI realise that by signing below I am authorising the Local Authority to contact me toconfirm the above informationSignature Date5) DETAILS FOR PAYMENTName of person the cheque should be made out to (please print clearly)If the Student’s name has NOT been entered above please confirm the relationshipof the name above to the studente.g. mother/ foster parent/guardian etc6) SCHOOL AND STUDENT DECLARATION (parent/carer may sign is student isunable to)I realise that by signing below I am confirming that the information given on this form iscorrect. I also understand that the Local Authority may check on the validity of any of theinformation given on this form and may deny payment if any information given provesincorrect.School Signature PLEASE SIGN AGAIN EVEN IF YOU HAVE COMPLETED 4.2 School & Name PositionSignature DateStudent (or parent/carer if applicable) SignatureI also confirm that I met the Residency Criteria as set out in Annex A of the Policy notesNameSignature DatePlease return the completed form to:Claire Ellis, 14-19 Manager, Education and Social Care, London Borough of Bexley,Hillview, Hillview Drive, Welling, DA16 3RYIf you have any queries please contact Claire Ellis on 0203 045 4222 orclaire.ellis@bexley.gov.uk

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