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SIMON BALLE SCHOOL – 16-19 BURSARY APPLICATION FORM Prior to completing this form please read the “16-19 Bursary Allocation Criteria” in order to establish whether or not you are eligible to apply. Proof of entitlement will be required to allow the processing of this form. Please hand this form to the School Finance Office by no later than Monday 31st October 2011. Please tick one of the following: I am applying for a full bursary of £1,200 (less any EMA payments received) I am applying for a discretionary bursary of up to £20 per school week.

Student’s Name ………………………………………… Form ……………… Student’s Bank Account – cheque to be made payable to …………..……... ……………………………………………………….…………………………….. Signature of Student …………………………………… Date ………………. Following section to be completed by the Parent/Carer: Full name …………………………………………………………………………. Address …………………………………………………………………………… ………………………………………………… Postcode ……………………… For discretionary bursaries please indicate under which criteria you are applying and attach evidence to this form to support the application, e.g. copy of letter of entitlement. Criteria Free School Meals (no need to provide evidence) Income Support Income-Based Job Seeker’s Allowance Support under Part VI of the Immigration & Asylum Act 1999 Child Tax Credit, provided the parent is not entitled to Working Tax Credit and an annual income assessed by HMRC which does not exceed £16,190. The guarantee element of State Pension Credit

I confirm that the details on this application are true and accurate.

Signature of Parent/Carer …………………………………Date ………………


16-19 Application Form