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 PAYMENTDiscretionary 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 DETAILSName 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 - DECLARATIONI 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 paymentName

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 USE ONLY

London Borough of Bexley Authorisation to pay:

Name Signature Date

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 Surname

Home Address

PostcodeDate of Birth E-mailDay time telephone number

2) COURSE & SCHOOL DETAILS (please print clearly)School attendingFull 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

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

A

Student currently receiving EMA (£10, £20, or £30 weekly allowance) in the 2010/11 Academic Year

Please provide – a copy of your EMA Notice of Entitlement or other correspondence from the Learner Support Service proving you are receiving EMA

B

Parents/Carer’s household income is below £30,810 in 2009-10 and/or 2010-11 financial year

Please provide – a copy of a recent Tax Credit Award Notice or other evidence (e.g. P60) from the Tax Office of the household annual income

B

Parent(s)/Carer(s) (or Student* if independent) are receiving welfare benefits

Please provide – a copy of recent correspondence or other written documents from the Benefit Agency confirming parent/carer/student is on benefits (* please 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)

DStudent is currently eligible for Free School Meals

Please ask a relevant member of staff at your school to complete the statement at 4.2

EStudent is currently in care or leaving care

Please ask your Connexions Advisor or Social Worker to complete the statement at 4.2

FStudent is currently on probation Please ask a relevant member of staff from

the Youth Offending Team or Probation to complete the statement at 4.2

GStudent is a young parent Please ask your Connexions Advisor or

Social Worker to complete the statement at 4.2

HStudent has not yet achieved 5 GCSEs A*- C including Maths & English

Please ask a relevant member of staff at your school to complete the statement at 4.2

IStudent has a disability and/or learning difficulty

Please ask your Connexions Advisor to complete the statement at 4.2

J Student is studying English as a Please ask a relevant member of staff at

second language your school to complete the statement at 4.2

K

Any other special financial circumstance not covered by the above, but which can be evidenced

Please state below your other financial circumstance and details of evidence you will supply

Page 3 BexdLS10-114.2) ADDITIONAL STATEMENT (where applicable for proof of eligibility)Student Name

I am the student’s

Delete as appropriate:SOCIAL WORKER / TEACHER / CONNEXIONS ADVISORIf other please state:

My name isMy day time contact number

My e-mail

I am signing to confirm the following

For example that the student is a parent etc (please see section 4)

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 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 relationship of the name above to the studente.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

NameSchool & Position

Signature Date

Student (or parent/carer if applicable) SignatureI also confirm that I met the Residency Criteria as set out in Annex A of the Policy notesNameSignature 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