Sir George Monoux College

Bursary and Free College Meal Application Form

Academic Year 2022/2023

Section 1: Learner Details – to be completed by the applicant – (student)

Please complete in capital letters and in black pen

Surname: Goldson…………………………………………………………………………………..

First name: Paris…………………………………………………………………………………

Student I.D Number: …

20221466……………………………………………………………………

Date of Birth: 28/03/2006…………………………………Age on the 05/10/22

16………………...

For Official Use Only Description Amount

Working Tax Credit £
Bursary FCM Child Tax Credit £
Approved: Income (work) £
Declined: Other £
Other £
Pending:
TOTAL £

Comments:

Initial Assessment………………………..….. Final Assessment………………………………

Staff Signature…………………………………. Staff Signature………………………………….

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Section 2: Residency – please circle the residency criteria that applies to you - to be completed by
the applicant (student)

Category Criteria

A
I am a British Citizen and have lived in the UK for at least three years prior to the start of my
learning programme.

I have ‘settled status’* and have been ordinarily resident in the UK for at least three years prior
B to the start of my learning programme.
*’Settled Status’ means having either indefinite leave to enter or remain or having the right of
abode in the UK.

C I am a national of an EU Country or child of an EU National and have been ordinarily resident

in the European Economic Area (EEA) or Switzerland for at least three years prior to the start
of my learning programme.

D I am the child of an EEA migrant worker or the child of a Swiss national or the child of a
Turkish Migrant Worker and have been ordinarily resident in the European Economic Area
(EEA) or Switzerland for at least three years prior to the start of my learning programme.

E I am the child of a refugee who has been granted Humanitarian protection, or have temporary
EU protection.

Section 3: Vulnerable Groups- to be completed by the applicant (student)

Please tick the group which applies to you, however, if you do not fall into any of the groups
listed, please tick the box indicated below none of the above.

I am in the care of my Local Authority

(You must enclose a letter from your Local Authority to confirm your circumstances)

I am currently receiving Universal Credit/Income Support

(You must enclose a letter from the Department of Work and Pensions as evidence)

I am a Care Leaver
(You must enclose a letter from your Local Authority to confirm your circumstances)

I am currently receiving Employment Support Allowance/Universal Credit and

Disability Living Allowance
(You must enclose a letter from the Department of Work and Pensions as evidence)

I am currently receiving Employment Support Allowance/Universal Credit and

Personal Independence Payment

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(You must enclose a letter from the Department of Work and Pensions as evidence

If none of the above categories apply to you, please tick this box.

Section 4: Guidance for Bursary and FCM (To be completed by Parent/carer)

This next section of the bursary and Free College Meal application needs to be completed by your parent/carer.
However, if you (the student) are living independently YOU will need to complete section 5.

In order to be eligible for the BURSARY your total household income must be less than £23,000. (This can be
made up from full/part time work, benefits and or pensions.) It includes all income to the household from any
persons residing at the stated address, all evidence must be provided.

In order to be eligible for FREE COLLEGE MEALS you must be in receipt of at least one of the benefits below
and have a household gross income of no more than £16,190. It includes all income to the household from any
persons residing at the stated address, all evidence must be provided.

Please note “Child Benefit” is not an income based benefit, therefore, receipt of it does not prove income nor can
it be used as proof to determine eligibility for the 16-19 Bursary Fund.

Section 5: Total Household Income to be completed by the Adult(s) responsible for the
Young Person (you will need to provide photocopies of current and relevant proof of receipt of benefits/income)

Adult 1 Adult 2

Surname: ………………………………… Surname: ……………………………………

First Name: ……………………………… First Name: …………………………………

Relationship to young person: Relationship to young people:

……………………………………………. ………………………………………………

Please tick the box which applies to you…
I currently receive:
Universal Credit
(You will need to provide a current Letter dated
from April 2016 onwards from the Department of
Work and Pensions)
Employment Support Allowance (ESA)
(You will need to provide a current Letter dated
from April 2016 onwards from the Department of
Work and Pensions)
Income Support
(You will need to provide a current Letter dated
from April 2016 onwards from the Department of
Work and Pensions)
Jobseeker’s Allowance (JSA)
(You will need to provide a current Letter dated
from April 2016 onwards from the Department of
Work and Pensions)
Pension Credit (Guarantee Credit)
(You will need to provide a current Letter dated
from April 2016 onwards from the Department of
Work and Pensions)
Employment/Self Employment
( Most recent P60/Accountant
statement/Employment contract post April 2016)
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Please tick the box which applies to you…
I currently receive:
Universal Credit
(You will need to provide a current Letter dated from
April 2016 onwards from the Department of Work
and Pensions)
Employment Support Allowance (ESA)
(You will need to provide a current Letter dated from
April 2016 onwards from the Department of Work
and Pensions)
Income Support
(You will need to provide a current Letter dated from
April 2016 onwards from the Department of Work
and Pensions)
Jobseeker’s Allowance (JSA)
(You will need to provide a current Letter dated from
April 2016 onwards from the Department of Work
and Pensions)
Pension Credit (Guarantee Credit)
(You will need to provide a current Letter dated from
April 2016 onwards from the Department of Work
and Pensions)
Employment/Self Employment
(Most recent P60/Accountant
statement/Employment contract Post April 2016)
 Working Tax Credit/Child Tax Credit
Award(TC602)
(Please provide your most recent Tax Credit
Award. April 2016 to April 2017. Please note we
require all pages)
Working Tax Credit/Child Tax Credit
Award(TC602)
(Please provide your most recent Tax Credit
Award. April 2016 to April 2017. Please note we
require all pages)

Section 6: Student Declaration –To be signed by the applicant (student)

 I declare that all information given on this form is true to the best of my knowledge
and belief
 I agree to supply any additional information that may be required
 I have read and understand the “Bursary and Free College Meal Guidance
Handbook” on the college website.
 I have not applied for a Bursary or Free College Meal at any other college or
institution
 I understand that this Bursary is for Educational purposes only and that I must
achieve 90% attendance at all timetabled classes in each term or payments will be
withdrawn or withheld.

Signature: P.Goldson………………………………………………… Date: …

5/10/22……………………

Print Name: …Paris…………………………………………....

Section 7: Parent/Carer Declaration– This declaration is to be signed by the

Parent(s)/Guardian/Carer of the applicant.

 I declare that all information given on this form and associated documents are true to
the best of my knowledge and belief.
 I have read and understand the “Bursary and Free College Meal Guidance
Handbook” on the college website.
 I understand that this Bursary is for Educational purposes only and that my
son/daughter must achieve 90% attendance at all timetabled classes in each term or
payments will be withdrawn or withheld.
 I understand that Sir George Monoux College may make any necessary enquiries to
verify my circumstances and I agree to supply any additional information that may be
required.
 I accept that public funds must be handled and managed appropriately and therefore
give my permission for the information provided to be used to prevent and detect
fraud.
 I understand that if I falsify any of the information recorded on this application, I am
liable and if found out will be made to repay the Bursary and/or Free College Meal
Award in full.

Signature 1: …J.Thomas………………………………………………… Date: ……

5/10/22…………………

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Print Name: …Janet Thomas……………………………………………

Signature 2: …………………………………………………… Date: ………………………

Print Name: ……………………………………………………

Please complete this sheet for our finance office. In order for payments to be
processed you will need to complete the form accurately and in full.

Section 8: Your Bank or Building Society Account Details – to be

completed by the applicant (student)
(To receive payments, you must ensure you have a bank account in your own name as it appears on
your passport. If not, you will need to open one before you can complete this application). Please attach a
photocopy of a recent bank statement as proof of your account details (please note we cannot process your
application without a recent bank statement)

Surname: …Goldson………………………………………………………………………………..

First name: Paris…………………………………………………………………………………

Student I.D Number: …

20221466……………………………………………………………………

Date of Birth: …28/03/2006……………………………Age on the 5/10/2022………16……...

Address: …23 The

Copse………………………………………………………………………………….

………………………………………………………………………………………………..

………………………………………… Post Code: ……E4 6BH…………………………………

Home Telephone: ………………………………………………………………………….

Mobile Telephone: …
07940200377………………………………………………………………………

Email Address: ……
goldsonparis@gmail……………………………………………………………………….

Name of Account Holder: …Master Paris

Goldson………………………………………………………………..
(this should be written as it appears on your card/bank statement and/or passport)

Name of Bank/Building Society: ……

NatWest………………………………………………………

Branch Name: …Ground Floor, Gredley House Natwest

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Stratford……………………………………………………………………………..

Sort Code: _60_ __ _05_ __ _26_ __

Account Number: _21848564_ __ __ __ __ __ __ __

(Your account number can be found on your bank/building society statement. Most account numbers are 8
digits long)

Roll Number: …………………………………………………………………………………

(only for building society accounts)