Disabled Student Allowances 2013/14 Application Form: SFE/DSASL/1314/B

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Disabled Student Allowances 2013/14 Application Form

SFE/DSASL/1314/B

the student finance experts

What do I need to do to get Disabled Students Allowances (DSAs)?


Here is a summary of the steps involved in applying for and receiving DSAs.

1 2 3 4 5 6
2

Fill in the application form


DSA

Complete and return this DSA application form with all of the requested evidence.

Find out if you qualify


Once we have received your application and all of your evidence we will assess your application and send you a letter to let you know if you qualify for DSAs or not.

?
REPORT

Attend a needs assessment


If you are eligible for DSAs you will need to arrange a needs assessment to identify any specialist equipment and other support that you may need for your course.

Receive your needs report


After you attend your needs assessment you will be sent a needs report, which identifies the equipment and other support you will need, how much it will cost, and where to get it from.

Find out what the DSAs can pay for


We will send you a letter to tell you whether any equipment and other support that has been recommended in your needs assessment can be paid for from DSAs. We will also give your instructions for ordering equipment or arranging other support.

Receive your support


Your funding will be paid direct to the supplier of the equipment or service.

SFE/DSASL/1314

Where can I find more information about Disabled Students Allowances?


Visit www.direct.gov.uk/studentfinance You can also find more information in the guide: Bridging the gap: A guide to the Disabled Students Allowances (DSAs) in higher education 2013/14. If you require this form or the above guide in Braille, large print or audio, please contact us.

How can I contact you?


Visit www.direct.gov.uk/studentfinance Contact us on 0845 300 50 90 or by textphone on 0845 604 4434 .

Instructions
Whenever you see this icon you must provide evidence to support your application. e

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section 1 personal details


Personal details
a Customer Reference Number Forename(s) Surname Sex Date of birth
2
0 7 9 6 1 8 9 0 7 5 9

Dammy Islamiat Shittu

Male
6 / 0

Female
1 /1 9 9 5

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

Postcode SE17 3QE Home phone number


02077035442

Postcode Date on which you will move to this address D D / MM/ Y Y Y Y


07904178557
[email protected]

Mobile phone number Email address

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section 2 other financial support


In academic year 2013/14 will you be eligible to apply for: a Department of Health or NHS bursary (excluding the social work bursary paid by the NHS Business Services Authority); or a Scottish Government Health Directorate Bursary (Scottish Healthcare Allowance); or a healthcare bursary from the Department of Health for Northern Ireland?

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.

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section 3 your disability, mental health condition or specific learning difficulty


a Please give full details and provide evidence of your disability, mental health condition or specific learning difficulty.

e Physical disability/mental health condition


You should provide a written medical statement from a doctor or appropriately qualified specialist, confirming the nature of your disability or mental health condition.

e Specific learning difficulty (for example, dyslexia)

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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section 3 your disability, mental health condition or specific learning difficulty


c Is this your first application for Disabled Students Allowances (DSAs)? Yes No
If Yes go to Section 4

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

section 4 your consent

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.

section 5 your bank or building society account details


Where possible we will pay suppliers of your equipment or support services directly. However, please complete the section below so that we can pay you if we need to. You do not need to provide these details if you have already given them to us. The account must be in your own name and be able to accept direct credits.
-

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 / /

SFE/DSASL/1314

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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