Confidential Application for Financial Assistance

How much are you applying for?

Childcare fund (£) (guidance)

Lone Parent Childcare Grant (£) (guidance)

Discretionary Fund (£) (guidance)

International Hardship Fund (£) (guidance)

First name*

Last name*

Email*

Term time address*

Home address (if different from term time address)

Mobile number*

Alternative contact number

Date of birth*

Marital status*

--please select-- Single Married Civil Partnership Cohabiting

Matriculation number*

Number of dependent children*

--please select-- 0 1 2 3 4 5

Any award made can only be paid into a UK bank account. Every UK account has a six digit sort-code and an eight digit account number.

Sort-code*

Account number*

Course title (eg BSc Psychology)*

Full time or part time?*

--please select-- Full time Part time

Number of modules (if part time)

Year of academic study*

--please select-- 1st Year Undergraduate 2nd Year Undergraduate 3rd Year Undergraduate 4th Year Undergraduate 5th Year Undergraduate 1st Year Postgraduate 2nd Year Postgraduate 3rd Year Postgraduate 4th Year Postgraduate 5th Year Postgraduate

Repeat year?*

--please select-- Yes No

Budget Statement for Academic Year (2 semesters), on average 34 weeks. Each box must show the total for the 34 weeks (multiply by 8 for monthly amounts).

See Guidance Notes for details. Consult the checklist at the end for details of documentary evidence required to back up these figures.

A total income of zero cannot be included in this step as it is expected that all students on course will have a form of income during the academic year. This could be a student loan/bursary, bank loan, family/parental/partners contribution, part-time earnings, savings or be in receipt of state benefits.

Student Loan (£)

Young Student Bursary (£)

Independent Student Bursary (£)

Parental Contribution (£)

Partner's Contribution (£)

Part-time Earnings (£)

Child Care Fund (£)

Lone Parent Childcare Grant (£)

Lone Parents' Grant (£)

Housing Benefit (£)

Disability Living Allowance/Personal Independence Payment (£)

Disabled Student Allowance (£)

Child Benefit (£)

Child Tax Credits (£)

Working Families Tax Credit (£)

Other (£)

Any other form of income (eg benefits not listed above, savings, child support from a former partner.)

Total (£)

Budget Statement for Academic Year (2 semesters), on average 34 weeks. Each box must show the total for the 34 weeks (multiply by 8 for monthly amounts).

See Guidance Notes for details. Consult the checklist at the end for details of documentary evidence required to back up these figures.

Rent/Mortgage (£)

Insurance (£)

Public Transport (£)

Private Transport (£)

Gas (£)

Electricity (£)

Phone (£)

Television (£)

Council Tax (£)

Books and Stationery (£)

Food and Personal Items (£)

Clothing (£)

Childcare (£)

Other Dependant's Care (£)

Loan Repayments and/or Credit Card repayments based on minimum monthly payments (£)

Tuition Fees (£)

Other (£)

Any other form of expenditure incurred during the academic year eg placement costs, gym membership etc. Please provide an explanation in your personal statement to support your application.

Total (£)

Your application will only be considered if you give a detailed account of the exceptional circumstances leading to your application.

Please review your application and confirm you understand the terms and conditions before sending.

I confirm that I have read the guidance information relating to the fund that I am applying to and understand what supporting evidence should be submitted so that the application can be considered.

I have read and understood our privacy statement and to the best of my knowledge and belief, the details I have given on this form are complete and accurate.