Disabled Student Allowances 2013/14 Application Form: SFE/DSASL/1314/B
Disabled Student Allowances 2013/14 Application Form: SFE/DSASL/1314/B
Disabled Student Allowances 2013/14 Application Form: SFE/DSASL/1314/B
SFE/DSASL/1314/B
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Complete and return this DSA application form with all of the requested evidence.
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REPORT
SFE/DSASL/1314
Instructions
Whenever you see this icon you must provide evidence to support your application. e
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Male
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Female
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Contact details
b Please give your current home address. If you know it, please also give your term-time correspondence address. Term-time address n
Home address
15 Berryfield Road Walworth London
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Yes
No
If Yes, you will not qualify for DSAs from Student Finance England. Please do not continue with this application. You should contact the provider of your bursary for advice on any extra support you may be entitled to because of a disability, mental health condition or specific learning difficulty.
SFE/DSASL/1314
You should provide a full diagnostic assessment carried out after your 16th birthday by a psychologist or suitably qualified specialist teacher. If you had a diagnostic assessment carried out before your 16th birthday it will usually require an update so we can fully assess how your study will be affected by your specific learning difficulty. It is your responsibility to pay any costs to obtain the required evidence.
b On what date was your disability, mental health condition or specific learning difficulty last assessed?
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If No, please provide details of each previous DSA funding application you have made. Date of application Funding authority applied to e / / / / / / / / / / / / / / / / e You must provide evidence showing the result of each previous DSA funding application and any DSA Needs Assessment Report you received from the funding authority. If you cannot provide the evidence requested, please provide full details of the funding you received in the box below. We may contact the relevant funding authorities for further information.
SFE/DSASL/1314
Please tick the boxes below if you consent to the following DSA arrangements. I agree that Student Finance England, the disability adviser at my university or college, and my DSA Needs Assessor may exchange information about my application for DSA where this is necessary to make sure I get the help I need. I agree that Student Finance England can give my address and phone number to the suppliers of any equipment I need so that delivery can be arranged. I agree that Student Finance England can directly pay the suppliers of equipment and support.
Sort code Account number Building society roll number (if applicable)
SFE/DSASL/1314
Declaration
Our Data Protection Statement sets out who will use the information provided on this form and what they will use it for. Before signing this form please read our statement online at www.direct.gov.uk/studentfinance-dataprotection. Alternatively, you can request a copy by writing to the Student Loans Company (SLC) at 100 Bothwell Street, Glasgow, G2 7JD or by calling us. I confirm that to the best of my knowledge and belief, the information I have provided is true and complete. If it is not I understand I might be refused financial support, or prosecuted and my financial support withdrawn. Your full name (in BLOCK CAPITALS) Your signature
Date / /
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Additional notes
If you are providing extra information below please clearly mark what section and question number the information is about.
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Checklist
Before returning this form, please make sure you have done the following: Signed and dated the declaration. Enclosed all the evidence requested to support your application. Any original evidence you send will be returned to you as soon as possible. e Please remember to pay the correct postage fee. Once you have completed this form, and signed and dated the declaration, please return it to us at: Student Finance England PO Box 210 Darlington DL1 9HJ
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