Fillable Claim for reimbursement of costs through Disabled Students (London Institute of Management and Technology)

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Claim for reimbursement of costs through Disabled Students (London Institute of Management and Technology)

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U.K. forms for London Institute of Management and Technology

BROWSE LONDON INSTITUTE OF MANAGEMENT AND TECHNOLOGY FORMS

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Dyddiad Geni
/ Eich Enw
Eich Cyfeiriad
/ Cwrs
/
Cyfeirnod Cwsmer
Côd Post
/ Manylion Personol
Hawlio ad-daliad costau trwy Lwfansau Myfyrwyr Anabl (DSA)
ar gyfer blwyddyn academaidd 2020/21
Prifysgol neu Goleg
• Costau teithio.
• Llyfrau Braille.
• Llun-gopïo.
• Defnyddiau traul (batris, cetris, papur).
• Costau ychwanegol llety prifysgol
neu goleg.
Sylwer nad yw hon yn rhestr gyflawn.
Os bydd angen gwybodaeth bellach
arnoch am yr hyn y gallwch hawlio
amdano, a fyddech gystal â ffonio
Canolfan Gyswllt Cyllid Myfyrwyr
Cymru ar 0300 200 4050.
Dylech lenwi’r ffurflen hon er mwyn hawlio unrhyw gostau y bu’n rhaid i chi eu
talu mewn cysylltiad â’ch astudiaethau ac o ganlyniad i reswm sy’n ymwneud â’ch
anabledd, eich cyflwr iechyd meddwl neu anhawster dysgu penodol. Er enghraifft:
SFW/DAEX/2021/A
Claim for reimbursement of costs through Disabled Students’
Allowances (DSA) for the academic year 2020/21
Personal Details
Customer Reference Number
Date of Birth /
Name
Address /
Postcode /
University or College /
Course
Complete this form to claim any costs you have had to pay in connection with
your studies due to a reason relating to your disability, mental health condition or
specific learning difficulty. For example:
• Travel costs.
• Books in Braille.
• Photocopying.
• Consumables (batteries, cartridges,
paper).
• Additional costs of university or
college accommodation.
Please note that this list is not
exhaustive. If you require further
information on what you are entitled
to claim for,
please call the Student
Finance Wales Contact Centre on
0300 200 4050.
Llofnod Dyddiad
Eich enw llawn
(mewn PRIFLYTHRENNAU)
Please complete the table over the page with details of your costs.
To find out how we’ll use the information you provide go to
www.studentfinancewales.co.uk/privacynotice to read our Privacy Notice before
signing this form.
Declaration
If you cannot sign this form, it must be signed on your behalf by your attorney. The
Power of Attorney letter must be sent with this form before a signature from that
attorney will be accepted.
• I certify I have incurred the expenses shown on this form.
• I undertake to inform you of any change that occurs.
Your full name
(in BLOCK CAPITALS)
I gael gwybod sut fyddwn ni’n defnyddio’r wybodaeth a roddwch, ewch i
www.cyllidmyfyrwyrcymru.co.uk/hysbyseb-preifatrwyddi ddarllen ein Hysbysiad
Preifatrwydd cyn llofnodi’r ffurflen hon.
Datganiad
Os na allwch lofnodi’r ffurflen hon, rhaid i’ch atwrnai ei llofnodi ar eich rhan. Rhaid
anfon llythyr y Pŵer Atwrnai gyda’r ffurflen hon cyn y derbynnir llofnod gan y atwrnai
hwnnw/honno.
• Tystiaf y bu’n rhaid i mi dalu’r costau a nodir yn y ffurflen hon.
• Byddaf yn eich hysbysu o unrhyw newid a fydd yn digwydd.
A fyddech gystal â llenwi’r tabl dros y dudalen gan nodi manylion eich costau.
SFW/DAEX/2021
Signed Date
Claim for reimbursement of costs through DSA 2020/21
Hawlio ad-daliad costau trwy DSA 2020/21
Please attach receipts or invoices as evidence of your purchases.
Please do not include items which are invoiced directly to us.
A fyddech gystal â chynnwys derbynebau neu anfonebau fel tystiolaeth o’r hyn a brynoch.
Ni ddylech gynnwys eitemau a fydd yn cael eu hanfonebu i ni yn uniongyrchol.
If we become aware of fraudulent activity we will share the supplier details you give us with
Cifas. You need to tell your suppliers that you’ve given us their details.
Os byddwn yn dod yn ymwybodol o weithgaredd twyllodrus, byddwn yn rhannu manylion y
cyflenwr a roddwch i ni gyda Cifas. Mae angen i chi ddweud wrth eich cyflenwyr eich bod
wedi rhoi eu manylion i ni.
Details of your costs
e.g. photocopying
Amount (£)
e.g. £1.00
Name and address of supplier
e.g. Printstore, 10 High Street
£
Total claimed
Cyfanswm yr hawliad
Manylion gwariant
e.e. llungopïo
Swm (£)
e.e. £1.00
Enw a chyfeiriad y cyflenwr
e.e. Siop Brint, 10 Stryd Fawr
SFW/DAEX/2021
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Claim for reimbursement of costs through Disabled Students (London Institute of Management and Technology)

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Completed 15 July 2021

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