16-19 Bursary Application Form: Student Section (A)
There are 3 main sections to this form - please read the questions carefully before answering.
Completed forms need to be sent along with any supporting evidence to Mrs R J Tomkinson,
Business Manager, Adams' Grammar School.
Student Details – answer all of the questions below and sign the declaration A6.
A1 Name
Surname/Family name
First name
/
A2 Date of birth
_/
A3 Home address
Postcode
Phone number
I will be applying/have already applied for a Telford & Wrekin/Shropshire Council travel passYes/No
A4 Eligibility Tick the answer that applies to your personal situation
(a)
I am a young person in Care (including Foster Care)
I am a Care Leaver
I receive Income Support or Universal credit and live independently of my
parents.
I am a disabled young person who receives both Employment Support
Allowance and Disability Living Allowance or Personal Independence
Payments.
If you received Income Support, please complete Benefits Income (C), questions C1, C2 and C5.
Section A1
A5 Eligibility Tick the answer that applies to your personal situation
(b)
I am a British Citizen/EU national and have been living in Britain/EU for the
past 3 years
I have settled status and have been ordinarily in the UK for the past 3 years
I am recognised as a refugee by the UK government
None of the other 3 options listed in part (b)
Privacy notice
The information that you provide on this form will be used to assess your eligibility for a 16-19
Bursary payment. This information may be shared with other organisations for administration and
statistical purposes; these could include the Education FundingAgency , the Department for Education
Telford & Wrekin Council. HAFT t/a Adams' Grammar School is registered under the
Data Protection Act 1998.
Declaration
If you give false or incomplete information, you may be prosecuted.
I have read and understood these questions and the Privacy Notice above and declare that the
information given on this form is correct and complete to the best of my knowledge and belief.
I understand that:
If I leave Adams' Grammar School I will not be eligible to receive further payments from
Adams' and may need to repay a proportion, or in exceptional cases all of the money paid to
me as part of this scheme.

I am not allowed to receive bursary payments at the same time as any other government
training or learning allowance (this does not include Income Support).

The information I have given may be shared with other agencies or organisations, as allowed
by the law, for the purpose of checking my application and/or the prevention of fraud.
A6 Signature
Date
By submitting this form and applying for a bursary you are agreeing to all of the statements and
conditions above.
Section A2
16-19 Bursary Application Form: Income Details (B)
To be filled in by the adults who are mainly responsible for the student making the application for a
bursary. If you received benefits during the last tax year (6 Apr 2015 to 5 Apr 2016) you may need to
complete Benefits Income (C).
B1 I am /We are the adults mainly responsible for:
B2 Fill in the details below if you are the adults responsible for the student and they live with you
Adult 1
Adult 2
Surname/Family
Name
First name
Relationship to
student
Your income for the tax year 2015/16
This is a necessary requirement for the assessment of the student’s eligibility and the size of any
discretionary bursary. Evidence will need to be provided to prove income for the tax year ending in
April 2015.
The easiest way to tell us about household income is to use your latest Tax Credit Award Notice
(TC602) as this includes all of the information required. This will record your total income.
B3 I am including form TC602
Yes
Total income recorded on the form
£
No
B4 Did you receive any state benefits
during the tax year 2015-2016 Yes / No
If you answered yes to question B4 complete questions B5 and B6, then section C on Benefits Income.
B5 Income from employment or self employment
Adult 1
Adult 2
Total earnings as an employee –
before tax and national insurance
Value of benefits in kind – from P9D
or P11D form
Total income from self-employment
Other income eg interest, dividends,
property income, pension etc
Total income
Section B1
Privacy notice
The information that you provide on this form will be used to assess student eligibility for a 16-19
Bursary payment. This information may be shared with other organisations for administration and
statistical purposes; these could include the Education Funding Agency for England, the
Department for Education, Telford & Wrekin Council. HAFT t/a Adams' Grammar School is
registered under the Data Protection Act 1998.
Declaration
If you give false or incomplete information, you may be prosecuted.
I/We have read and understood these questions and the Privacy Notice above and declare that the
information given on this form is correct and complete to the best of my knowledge and belief.
I/We understand that:

I/We share responsibility for the information given with any partner named on this form.

If the student leaves Adams’ Grammar school he/she will not be eligible to receive further
payments and may need to repay a proportion, or in exceptional cases all of the money paid
to him/her as part of this scheme.

The information given may be shared with other agencies or organisations, as allowed by the
law, for the purpose of checking this application and/or the prevention of fraud.
B6 Signature 1
Date
B6 Signature 2
Date
By submitting this form and applying for a bursary you are agreeing to all of the statements and
conditions above.
Section B2
16-19 Bursary Application Form: Benefit Income (C)
Who needs to fill in this section?

Any student who is receiving Income Support at the time of filling the form in and has the
appropriate evidence to show this. Answer questions C1, C2 + C5.

Any parent or carer who received any of the benefits below between 6 April 2015 and 5 April
2016 answer C1, C3, C4 and C5. It is not necessary to complete this form if you are sending in
a Tax Credit Award Notice.
Student
C1 Name
Surname/Family name
First Name
C2 I am currently in receipt of Income Support
Date started
Adult 1
C3 Surname
First Name
Benefits received during the year
Benefit
Whole
Year
Part
Year
From
(Date)
To
(Date)
From
(Date)
To
(Date)
Income Support, Income-based Jobseekers
allowance, Income-related Employment
and Support Allowance or Pension Credit
Carer’s Allowance
Contribution-based Employment and
Support Allowance
Contribution-based Jobseekers Allowance
Incapacity Benefit
Bereavement Allowance
Adult 2
C4 Surname
First Name
Benefits received during the year
Benefit
Whole
Year
Part
Year
Income Support, Income-based Jobseekers
allowance, Income-related Employment
and Support Allowance or Pension Credit
Carer’s Allowance
Contribution-based Employment and
Support Allowance
Contribution-based Jobseekers Allowance
Incapacity Benefit
Bereavement Allowance
Section C1
Any additional information, eg changes in circumstances
Privacy notice
The information that you provide on this form will be used to assess student eligibility for a 16-19
Bursary payment. This information may be shared with other organisations for administration and
statistical purposes; these could include the Education Funding Agency for England, the
Department for Education, Telford & Wrekin Council. HAFT t/a Adams' Grammar School is
registered under the Data Protection Act 1998.
Declaration
If you give false or incomplete information, you may be prosecuted.
I/We have read and understood these questions and the Privacy Notice above and declare that the
information given on this form is correct and complete to the best of my knowledge and belief.
I/We understand that:

I/We share responsibility for the information given with any partner named on this form.

If the student leaves Adams' he/she will not be eligible to receive further payments from
Adams' and may need to repay a proportion, or in exceptional cases all of the money paid to
him/her as part of this scheme.

The information given may be shared with other agencies or organisations, as allowed by the
law, for the purpose of checking this application and/or the prevention of fraud.
C6 Signature 1
Date
C6 Signature 2
Date
By submitting this form and applying for a bursary you are agreeing to all of the statements and
conditions above.
Section C2