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 a
bank 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 DETAILS
Name of Student
Address
Bank/Building
Society Account
is registered to Postcode
A2) DETAILS FOR PAYMENT – ACCOUNT DETAILS
Name of Bank/
Building Society
Account Number
Sort Code - -
Building Society Roll Number
Account Holders Name (Block Capitals please)
This should be your name as it appears on your cash statements
If the payment is not to be made into the student’s account please explain where the payment is
being made and why
A3) DETAILS FOR PAYMENT - DECLARATION
I can confirm that the details contained on this form are correct and that I authorise the London
Borough of Bexley to check on validity of this information and to use my Account details to
make the discretionary Learner Support payment
Name
Signature Date
Please return the completed form to:
Claire Ellis, 14-19 Manager, Education and Social Care, London Borough of Bexley, Hillview,
Hillview Drive, Welling, DA16 3RY
If you have any queries please contact Claire Ellis on 0203 045 4222 or claire.ellis@bexley.gov.uk
FOR 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 form
1) PERSONAL & CONTACT DETAILS FOR STUDENT (please print clearly)
First Name Surname
Home Address
Postcode
Date of Birth E-mail
Day time telephone number
2) COURSE & SCHOOL DETAILS (please print clearly)
School attending
Full details of course(s) being
studied
Date course(s) started
3) DETAILS OF SPECIFIC HARDSHIP NEED (Please print clearly)
Please tick relevant box(es) Estimated Cost
Special 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 reached
the estimated costs included

3. Page 2 BexdLS10-11
4) 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 from
A
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 (* please
B
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 at
D Free School Meals your school to complete the statement at
4.2
Student is currently in care or Please ask your Connexions Advisor or
E leaving care Social Worker to complete the statement at
4.2
Student is currently on probation Please ask a relevant member of staff from
F the Youth Offending Team or Probation to
complete the statement at 4.2
Student is a young parent Please ask your Connexions Advisor or
G Social Worker to complete the statement at
4.2
Student has not yet achieved 5 Please ask a relevant member of staff at
H 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 to
I
learning difficulty complete the statement at 4.2
Student is studying English as a Please ask a relevant member of staff at
J 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
evidenced
K

4. Page 3 BexdLS10-11
4.2) ADDITIONAL STATEMENT (where applicable for proof of eligibility)
Student Name
Delete as appropriate:
I am the SOCIAL WORKER / TEACHER / CONNEXIONS ADVISOR
student’s If other please state:
My day time
My name is
contact number
My e-mail
For example that the student is a parent etc (please see section 4)
I am signing to
confirm the following
I realise that by signing below I am authorising the Local Authority to contact me to
confirm the above information
Signature Date
5) DETAILS FOR PAYMENT
Name 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 relationship
of the name above to the student
e.g. mother/ foster parent/guardian etc
6) SCHOOL AND STUDENT DECLARATION (parent/carer may sign is student is
unable to)
I realise that by signing below I am confirming that the information given on this form is
correct. I also understand that the Local Authority may check on the validity of any of the
information given on this form and may deny payment if any information given proves
incorrect.
School Signature PLEASE SIGN AGAIN EVEN IF YOU HAVE COMPLETED 4.2
School &
Name Position
Signature Date
Student (or parent/carer if applicable) Signature
I also confirm that I met the Residency Criteria as set out in Annex A of the Policy notes
Name
Signature Date
Please return the completed form to:
Claire Ellis, 14-19 Manager, Education and Social Care, London Borough of Bexley,
Hillview, Hillview Drive, Welling, DA16 3RY
If you have any queries please contact Claire Ellis on 0203 045 4222 or
claire.ellis@bexley.gov.uk