Delayed Funding LoanApplication Form 2017/2018

Name:

Student Number:

IMPORTANT!READ THIS BEFORE COMPLETING THE

APPLICATION FORM

This form is only for home students whose first instalment of Student Loan or NHS Bursary has been delayed.

A Delayed Funding Loan is a very short term loan from the University’s Financial Assistance Fund. It must be repaid promptly and in full to enable the University to continue providing financial support to students who are experiencing financial hardship.

Our priority groups include disabled students, students from low income homes and students who are supporting a family. Students in these groups should also submit a Financial Assistance Fund Application, available from money@chester.ac.uk. This will be used to assess your financial situation to see if you are eligible for a non-repayable award from the hardship fund.

Failure to repay the Delayed Funding Loan may result in legal action being taken. If you qualify for a university bursary, we may also recover some or all of your outstanding loan from any unpaid instalments of bursary.

All communication regarding your Delayed Funding Loan will be sent to your University email account. It is your responsibility to check your University email account regularly.

By completing and signing this form you are agreeing to these conditions.

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Part 1 - Personal DetailsStudent Number Date of Birth

Title Mrs Mr Miss Other

First Name(s)

Surname

Term Time Address

Contact Address - Yes/No

Postcode

Home Address

Contact Address - Yes/No

Postcode

Contact details – please include dialling codes where applicable

Home telephone

Term time telephone

Mobile

Email Address

Part 2 – Your DependantsDo you have any children or adults who are financially dependent on you?

No Yes please give details

Full Name Date of Birth Do they live with you? Age

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Part 3 – BenefitsWere you claiming benefits prior to enrolling at University? Yes No

If yes, please state which benefits you were entitled to and how much you were claiming (please give weekly amounts)

Benefit Amount per week

Part 4 – Course DetailsCampus Chester Warrington Nursing

Course title

Diploma 1st Degree Postgraduate

Date of start of course Month Year

What year are you in now? 1 2 3 4 5

Part 5 – Exceptional NeedIt is expected that the maximum loan requested would be no more than £100.00 per fortnight (students with dependent children may be eligible for a slightly higher loan if required).

If you have an exceptional need that would require more than this amount, please state the reasons why you consider this an exceptional need. You must provide supporting evidence and copies of three months’ most recent statements for all bank accounts. Please include explanations for any transactions of £100 or more, paid in or out.

Amount requested (whole pounds only in multiples of £10)£

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Part 6 – Student Finance / NHS InformationName of funding provider

Have you contacted Student Finance / NHS Bursaries to begin the application process? Yes No

IF NO, state reasons why not

IF YES, provide evidence and state the approximate date of your initial contact

Have you contacted your funding provider since this initial contact to find out what stage your application has reached? Yes No

IF NO, state reasons why not

IF YES, state date of latest contact

What was their answer?

Have you recently decided to change your course? Yes No

IF YES, have you informed your funding provider so your application can be reassessed? Yes No

Have you explored all other sources of funding for example, parental contribution, bank overdraft, savings etc? Yes NoIF NO, please state reasons why not

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Part 7 – Bank DetailsConfirm your bank details to enable payment directly into your bank account. Please write digits clearly and use block capitals to ensure the information is legible.

Bank

Sort Code

Account Number

Account Name

Reference number – for Building Society Accounts

Part 8 – DeclarationI hereby certify that the information I have provided is correct and that the amount of loan I have applied for is a true reflection of my current financial needs.

I further understand that the amount allocated to me MUST be repaid and I must inform the Student Support Finance Team when I have received my funding to enable repayment to be taken.

If I withdraw or suspend my studies before I receive my Student Loan, I must make arrangements to repay the amount allocated to me in full, at the date on which I withdraw or suspend my studies.

Signed Date

Data Protection Act 1998

The data collected in this form will only be used to determine an applicant’s suitability to receive a Delayed Funding Loan. All awards will be made at the discretion of the Student Support Funds Officer. The information will not be used for any other purpose unless you have given your express consent.

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THIS IS A VERY SHORT TERM LOAN WHICH MUST BE REPAID IN FULL

Are you able to give debit/credit card details to repay this loan? Yes No

IF NO, you will need to provide an alternative repayment method e.g. card details for a parent or friend. Your application will not progress without this information. If you cannot provide this information please discuss with a member of Student Welfare.

IF YES, please enter details below in BLOCK CAPITALS:

Student Details Cardholder details (if not Student)

Name Name

Address Address

Tel No Tel No

Student Number

Cardholder Name

Card NumberThis is the long number across the centre of the card

Valid From Expiry Date

MUST BE AFTER REPAYMENT DATE

Issue no

Last 3 digits of security number on reverse of the card

Issuing Bank/Building Society

Card Type:Switch / Maestro Solo

Visa MasterCard

It is your responsibility to inform the Student Support Finance Team when you are able to repay your loan.

If you do not contact us we will attempt to take repayment from you as follows:

Loans processed in term 1 – repayment in week commencing 15th January 2018Loans processed in term 2 – repayment in week commencing 16th April 2018Loans processed in term 3 – repayment 4 weeks after loan issued

It is your responsibility to tell us if you have insufficient funds to make this repayment.

Office Use Only: Delayed Funding Loan Amount (please state in figures and text)

Failure to repay the Loan may result in legal action being taken. If you qualify for a university bursary, we may recover some or all of your outstanding loans from any unpaid instalments of bursary.