SFE/DSASL/1314/B

Disabled
Student
Allowances
2013/14
Application Form
the student nance 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.
?
DSA
REPORT

1
Fill in the application form
Complete and return this DSA application form with all of
the requested evidence.
2
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.
3
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.
4
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.
5
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.
6
Receive your support
Your funding will be paid direct to the supplier of the
equipment or service.
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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.
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section 1 personal details

Personal details
a Customer Reference
Number
Forename(s)
Surname
Sex
Male Female
/ /
Date of birth
Contact details
b Please give your current home address. If you know it, please also give
your term-time correspondence address.
Home address
Postcode
Term-time address
Postcode
Date on which you will move to this
address Home phone number
/ /
Mobile phone number
Email address
n
D D M M Y Y Y Y
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?
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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Yes No
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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.
/ /
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b On what date was your disability,
mental health condition or
specific learning difficulty last
assessed?

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.




















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Date of application Funding authority applied to
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.
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 ser-
vices 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)
- -
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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.
Date
Your full name (in BLOCK CAPITALS)
Your signature
/ /
X
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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.


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Enclosed all the evidence requested to support your application. Any original
evidence you send will be returned to you as soon as possible.
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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