Welsh for Adults Form [English] (PDF)

Office Use
WFA FCF 15
WFA Enrolment No:

WELSH FOR ADULTS
FINANCIAL CONTINGENCY FUND FORM
Please note that the following strict closing dates for submission of this form apply:
Friday 7th November 2014 for students starting their course in September 2014
If you start your course after November 2014, the closing date for submission of this
form is 13th February 2015
Full Name:

Title:

Full Address:

Date of Birth:
Phone:

Postcode:

Email address:

Course Details
Level of Course:

Course Location:

Course Tutor:

Day and Time of Course:

Duration of Course in weeks (i.e 15 / 20 or 30 weeks)

Travel Costs
Do you incur travel costs to attend your Welsh for Adults course?
How many miles, approximately, do you travel to your class?
Do you use public transport?

YES / NO
miles

YES / NO

How much does it cost you to attend the course each week? £

per week

Additional Costs
Please list the type and amount of additional costs you have incurred or expect to incur for this academic year:
Books £

Exam fees

£

Extra curricular activities* (please detail below): £

*excluding Sadwrn Siarad

Childcare Costs
Do you have dependant children?
Full name

YES / NO (please list in table below)
Age

Relationship to you

Do they live with you?

Do they attend school?

Do you incur childcare costs to attend your Welsh for Adults course?
YES / NO
If so, how much does childcare cost each week to enable you to attend this course?
£

per week

You will need to provide evidence of your childcare costs such as a copy of an invoice, receipt of
payment or letter of confirmation from your childcare provider.

Personal Details
Are you, or your spouse/partner, in receipt of one of the following? (please tick)

YES / NO

Pension credit
Job seekers allowance (income assessed only)
Income support
Incapacity benefit / Severe disablement benefit
Housing benefit
Council tax benefit
Working tax credit
Employment Support Allowance (income assessed only)
If YES, you must provide proof of your entitlement by supplying a copy of the relevant benefits letter.
If you are under 18, are your parents in receipt of one of the above listed benefits? YES / NO
If YES, you must provide proof of your parent’s entitlement by supplying a copy of the relevant
benefits letter.
Current financial position
If you have indicated above that you are in receipt of one of listed benefits and are supplying evidence
of this with application form, you do not have to provide statements.
If you are not claiming one of the benefits listed above, you must provide a photocopy of one month’s
worth of your (and your spouse / partners) bank statements, dated within 2 months of the date of
application, for all accounts you hold. The photocopies should contain your name so that the Student
Money Advice Team can identify that it is your bank statement.

Bank Account Details
Please list details of all accounts held by you and your spouse / partner (if applicable). Please note any award from the
fund will be paid into the first account listed and this must therefore be an account in your name or a joint account.
1

2

3

Name of account holder
Bank / Building Society name
Account number
Sort Code
Roll no. (If applicable)
Current balance
Please indicate here any further information you feel may be relevant:

Declaration
You must ensure that you have read and understood the terms & conditions and the Data Protection Statement.
By signing the declaration on the form below, you are agreeing to the terms and conditions and accepting the data
protection statement below:
Terms and conditions declaration
• I am an eligible ‘home’ student. This normally means that you are a UK citizen and you have been living in the
UK for 3 years prior to the first day of your course, and that the purpose for you living in the UK was not to
receive full-time education. If you do not meet this criteria please contact the Student Money Advice Team on
01443 483778 for advice.
• I have not made a decision to study at the Glamorgan Welsh for Adults Centre based solely on the
outcome of this application. I understand fully that awards are not guaranteed.
• I have fully completed the form and enclosed the relevant documentation (as requested) and understand that if
an item is missing or incorrect my application will be delayed or rejected.
• The information given on this form is accurate and complete to the best of my knowledge and belief and I
undertake full legal responsibility for it.
• I will inform you immediately of any alterations to the particulars given.
• I accept that the Committee reserves the right to request further information or clarification on the information
supplied and I am agreeable to any investigation made to verify the accuracy of the information given within
the terms of the data protection act 1998.
• I undertake to repay any amount awarded which is subsequently found to be based on inaccurate information.
• I understand that the Department for Work and Pensions has the power to request information about my
application and any award from the University of South Wales in order to assess my entitlement to benefits.
• I undertake to repay any amount that is awarded to me in error.

Data Protection Act
All personal details will be held in accordance with the Data Protection Act 1998. The information provided in this
application and any documents submitted may be used by University of South Wales staff in the Student Money
Advice Team, Welsh for Adults Centre, the Finance division, the head of Student Services (or nominee), internal
auditors, the Financial Contingency Fund Committee, an independent appeals adjudicator, and externally by
representatives from the Welsh Government (including any auditors). All of the above may have access to your
application for making decisions, presenting cases and auditing purposes. Representatives from the Department
for Work and Pensions have the power to access information from your application for processing benefit claims.
Explicit consent will be sought if the information is requested from any other source or for any other purpose.

X

Signature:

Date:

Submission of application
You should return this form and all documentation to:
Welsh for Adults Centre
Financial Contingency Fund application
University of South Wales
Treforest
Pontypridd
Rhondda Cynon Taf
CF37 1DL