Fillable DSA1 2021/22 Application for Disabled Students Allowance (DSA) (London Institute of Management and Technology)

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DSA1 2021/22 Application for Disabled Students Allowance (DSA) (London Institute of Management and Technology)

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1
SFW/DSA1F/2122/EN/A
2021/22
DSA1
Application for Disabled
Students’ Allowance (DSA)
We welcome applications in Welsh. This won’t lead to a delay in our response.
Your forename(s)
Your surname
If you have applied for student finance before,
please provide your Customer Reference Number
Instructions
•
To obtain this form in an alternative format such as Braille, large print or audio please
email: brailleandlargefonts@slc.co.uk or call 0141 243 3686.
• Answer all the questions. If you leave any question blank we will not be able to
process your application. If a question does not apply to you, please enter ‘None’ or
‘N/A’ as the answer.
• Please refer to the DSA1 notes each time you see this icon.
• Whenever you see the evidence icon, you must provide evidence to support your
application. Information about the evidence required can be found in the DSA1 notes
and will also be marked with this icon.
• Sign and date the Terms and Conditions.
• Return your form to:
Student Finance Wales
PO Box 211
Llandudno Junction
LL30 9FU
• If you have any questions call the Student Finance Wales Contact Centre on
0300 200 4050.
To find out how we’ll use the information you provide go to
www.studentfinancewales.co.uk/privacynotice to read our Privacy Notice before
completing this form.
You may be eligible for a bursary or scholarship. In order for a university or college to
determine and pay any bursary or scholarship to which you may be entitled, we will share
some of your personal, financial and course details as well as information about your eligibility
for student finance with them. For more information about this, read our Privacy Notice.
Please contact the university or college if you require further information about their bursaries
and scholarships.
facebook.com/SFWales twitter.com/SF_Wales
2 SFW/DSA1F/2122/EN
Section 1 - personal details
a
/
/
/
/
Personal details
Title Mr Mrs Miss Ms
Forename(s)
Surname
If you have a double-barrelled surname
please ensure you put both parts of your surname with a hyphen in between, if applicable.
Any other names you
may be known by
Sex
Male Female Date of birth
Day Month Year
Please complete these questions with the details exactly as stated on your birth
certificate or passport.
Place of birth (town/village)
Nationality
Identity evidence details
b1
Do you hold a UK passport?
Yes
No
If ‘No’ go to b3
b2
Provide the following details from your UK passport, which must be
currently valid and not expired (this is the easiest way for you to verify
your identity and means you do not need to send us your passport).
If your passport is not valid or has expired, go to b3
Passport number
Forename(s)
Surname
Date of issue
Date of expiry
b3
Send your non-UK passport or Biometric Residence Permit;
or
Send your original UK birth or adoption certificate.
3SFW/DSA1F/2122/EN
Continued
Section 1 - personal details
c
Previous loans
Have you ever had any other loans from the
Student Loans Company Limited (SLC)?
Yes
No
if ‘No’ go to d
If ‘Yes’, are you behind with the repayments?
Yes No
d
Contact details
Please give your current home address. If you know it, please also give your
term-time correspondence address.
Home address
Postcode
Home phone number
Term-time address
Postcode
Date on which you will move to your
term-time address
Day Month Year
Mobile phone number
Email address
What language would you like us to use on the
letters we send you?
English
Welsh
d1 Did you move to Wales wholly or mainly for
the purpose of receiving Higher Education? Yes
No
If ‘Yes’ please contact
Student Finance Wales
e1
Armed Forces
Are you a member of the Armed Forces serving
outside Wales?
Yes No
e2 Are you a family member of someone in the Armed
Forces serving outside Wales?
(for example: spouse or child)
Yes No
4 SFW/DSA1F/2122/EN
!
Section 2 - other nancial support
Bursaries and awards
If you are an undergraduate student in this academic year will you be eligible
to apply for:
• a Department of Health or NHS bursary (excluding the social work
bursary paid by the Care Council for Wales); or
• a Scottish Government Health Directorate Bursary (Scottish Healthcare
Allowance); or
• a healthcare bursary from the Department of Health, for Northern Ireland?
Yes No
If you are a postgraduate student in this academic year will you be eligible to
apply for:
• a Department of Health, NHS, Scottish Government Health Directorate
(Scottish Healthcare Allowance) or other healthcare bursary; or
• a Research Council bursary; or
• a Care Council for Wales bursary for students studying an approved
postgraduate social work course; or
• a bursary from your college or university that includes extra support
because of your disability, long-term health condition, mental health
condition, specific learning difficulty or autism spectrum disorder
(do not count any payment you get from your university or
college hardship fund)?
Yes No
If you have answered ‘Yes’ to either of the above questions, you will not
qualify for DSA from Student Finance Wales. Please do not continue with
this application. You should contact the provider of your bursary for advice
on any extra support you may be entitled to because of a disability, long-
term health condition, mental health condition, specific learning difficulty or
autism spectrum disorder.
5SFW/DSA1F/2122/EN
Section 3 - residence
a1
Nationality
Are you a UK national?
No
if ‘No’ go to a2
–
Yes now go to b1
a2 Are you an Irish citizen?
No
if ‘No’ go to a3
Yes have you been resident in the UK and
Islands for the three years prior to the
rst day of the rst academic year of
your course?
No
if ‘No’ go to a3
Yes
now go to b2
a3 Are you the family member of a UK
national, and both you and your UK
national family member were living:
• in the UK on 31 December 2020, after
moving to the UK from the EEA or
Switzerland on or after 1 January 2018; or
–
• in the EEA or Switzerland on 31
December 2020?
No
If ‘No’ go to a4
Yes have both you and your family member
been resident in the UK, Gibraltar, EEA
or Switzerland for three years prior to
the rst day of the rst academic year
of your course?
No
If ‘No’ go to a4
Yes
now go to b2
a4 Have you been granted settled status
or pre-settled status under the EU
Settlement Scheme?
No
if ‘No’ go to a5
Yes – settled
status
Please provide your share code
now go to b2
Yes – pre-settled status
Are you an EU national and have been
resident in the UK and Islands for
three years prior to the rst day of the
rst academic
year of
your course?
No
if ‘No’ go to a5
Yes
Expiry date of pre-settled status
Day Month Year
Share code
now go to b2
6 SFW/DSA1F/2122/EN
Section 3 - residence
Continued
a5 Are you the child of a Swiss national?
–
No
if ‘No’ go to a6
Yes were you resident in the UK, Gibraltar,
EEA or Switzerland for three years
prior to the rst day of the rst
academic year of your course?
No
if ‘No’ go to a6
Yes – provide your:
Expiry date of pre-settled status
Day Month Year
Share code
If your parent or step-parent
has settled or pre-settled status
under the EU Settlement Scheme,
provide their:
Date of birth
Day Month Year
Expiry date for pre-settled status
Day Month Year
Share code
now go to b2
a6 Are you or your:
• husband, wife, civil partner; or
• parent(s), step-parent; or
• child, step-child
an EEA or Swiss national who is working, or
has worked or is looking for work in the UK?
–
–
No
if ‘No’ go to a7
Yes I have been working or
looking for work in the UK.
Yes my family member has been working
or looking for work in the UK. My
family member is my:
husband/wife/civil partner
parent(s)/step-parent
child/step-child
7SFW/DSA1F/2122/EN
Section 3 - residence
Continued
a6 continued
Have you been resident in the UK,
Gibraltar, the EEA or Switzerland for the
three years prior to the rst day of the rst
academic year of your course?
No
if ‘No’ go to a7
Yes – provide details of your/your family
member’s employment. You should also
provide details of your previous study.
If you/your family member are currently
working, will you/your family member
continue to work during your studies?
No
if ‘No’ go to a7
Yes – provide details:
Provide your:
Expiry date of pre-settled status
Day Month Year
Share code
now go to b2
Provide your family member’s:
Date of birth
Day Month Year
Expiry date of pre-settled status
Day Month Year
Share code
now go to b2
8 SFW/DSA1F/2122/EN
Section 3 - residence
Continued
a7 Are you the child of a Turkish Worker
who is working in the UK?
No
if ‘No’ go to a8
Yes – has your Turkish worker parent/
step-parent been granted extended
Leave to Remain in the UK after 31
December 2020 by the Home Oce?
No
if ‘No’ go
to a8
Yes – were you and your Turkish
worker parent/step-parent
living in the UK by 31
December 2020?
No
if ‘No’ go to a8
Yes
now go to b2
a8 Do you have settled status in the UK,
that was not granted under the EU
Settlement Scheme?
No
if ‘No’ go to a9
Yes – provide your:
Home Office reference number
Date latest status granted
Day Month Year
now go to b1
a9 Have you or your:
• husband, wife, civil partner; or
• parent(s), step-parent
been granted refugee status by the UK
government?
No
if ‘No’ go to a10
Yes – provide your:
Home Office reference number
Date latest status granted
Day Month Year
Date this status is due to expire
Day Month Year
Have you lived outside the UK and Islands
since your latest status was granted?
No
go to section 4
Yes
if ‘Yes’ go
to b3
9SFW/DSA1F/2122/EN
a10 Have you or your:
• husband, wife, civil partner; or
• parent(s), step-parent
been granted ‘leave to remain’ as a
Stateless Person?
No
if ‘No’ go to a11
Section 3 - residence
Continued
Yes – provide your:
Home Office reference number
Date status granted
Day Month Year
Date this status is due to expire
Day Month Year
Have you lived outside the UK and Islands
since your latest status was granted?
No
go to section 4
Yes
if ‘Yes’ go
to b3
a11
Have you or your:
• husband, wife, civil partner; or
• parent(s) or step-parent
been given:
• ‘leave to enter or remain’ in the UK on the
grounds of family or private life; or
• ‘leave to enter or remain’ in the UK following
a failed application for ‘leave to enter or
remain’ on the grounds of family or private life
on the grounds of Article 8 of the European
Convention on Human Rights (ECHR); or
• Discretionary Leave as a result of a failed
asylum application; or
• Discretionary Leave where no application for
asylum has been made?
No
if ‘No’ go to a12
Yes – provide your:
Home Office reference number
Date latest status granted
Day Month Year
Date this status is due to expire
Day Month Year
now go to b3
10 SFW/DSA1F/2122/EN
Section 3 - residence
Continued
a12 Have you or your:
• husband, wife, civil partner; or
• parent(s) or step-parent
been granted Humanitarian
Protection?
No
if ‘No’ go to a13
Yes – provide your:
Home Office reference number
Date latest status granted
Day Month Year
Date this status is due to expire
Day Month Year
now go to b3
Have you lived outside the UK and Islands
since your latest status was granted?
No
go to section 4
Yes
if ‘Yes’ go to b3
a1
3
Have you been granted ‘leave to remain’ in
the UK under section 67 of the Immigration
Act 2016, or are you the dependant child of
someone who has?
No
if ‘No’ go to a14
Yes – provid
e your:
Home Office reference number
Date status granted
Day Month Year
Date this status is due to expire
Day Month Year
Have you lived outside the UK and Islands
since your latest status was granted?
No
go to section 4
Yes
if ‘Yes’ go
to b3
11SFW/DSA1F/2122/EN
Section 3 - residence
Continued
a14
Have you been granted ‘Calais leave’ in
the UK, or are you the dependant child of
someone who has?
No
if ‘No’ go to a15
Yes – provide your:
Home Office reference number
Date latest status granted
Day Month Year
Date this status is due to expire
Day Month Year
Have you lived outside the UK and Islands
since your latest status was granted?
No
go to section 4
Yes
if ‘Yes’ go
to b3
a15
Ha ve you been granted ‘leave to
remain’ in the UK as a vi
ctim of
domestic violence or abuse, or are
you the dependant child of someone
who has?
No
if ‘No’ go to a16
Yes – provid
e your:
Home Office reference number
Date status granted
Day Month Year
Date this status is due to expire
Day Month Year
now go to b3
a16
Have you been granted ‘leave to remain’ as
a person who has been a bereaved partner,
or are you the dependant child of someone
who has?
No
if ‘No’ see below
Yes – provide your:
Home Office reference number
Date status granted
Day Month Year
Date this status is due to expire
Day Month Year
now go to b3
If you answered ‘No’ to all the questions in this section you are not eligible for student
finance from Student Finance Wales.
!
12 SFW/DSA1F/2122/EN
Section 3 - residence
Continued
b1 In the three years prior to the start of the rst
academic year of your course, did you live
outside the UK and Islands at any time?
No
Yes
now go to b2
b2 Give details of your residence for the three years before the start of the rst academic year
of your course. For example: if your course starts in September 2021, we need to know
where you lived between 01/09/2018 and 01/09/2021. If your course starts in March 2022,
we need to know where you lived between 01/01/2019 to 01/01/2022.
There should be no gaps in the dates you give us.
Full Address
From
Day Month Year
To
Day Month Year
Why were you there?
Full Address
From
Day Month Year
To
Day Month Year
Why were you there?
Full Address
From
Day Month Year
To
Day Month Year
Why were you there?
Full Address
From
Day Month Year
To
Day Month Year
Why were you there?
now go to b4
13SFW/DSA1F/2122/EN
Section 3 - residence
Continued
b3 Give details of your residency from the date you received your last status from the Home
Oce to the rst day of the rst academic year of your course. There should be no gaps in
the dates you give us.
Full Address
From
Day Month Year
To
Day Month Year
Why were you there?
Full Address
From
Day Month Year
To
Day Month Year
Why were you there?
Full Address
From
Day Month Year
To
Day Month Year
Why were you there?
Full Address
From
Day Month Year
To
Day Month Year
Why were you there?
now go to b4
14 SFW/DSA1F/2122/EN
Section 3 - residence
Continued
b4 At any time since 1 September 2018 has:
• either of your parents, step-parents,
guardians; or
• your husband, wife, civil partner
lived or worked outside the UK and Islands
or, in the case of an EU, EEA or Swiss
national, outside the EEA or Switzerland?
No
if ‘No’ go to section 4
Yes
if ‘Yes’ give details below
Full Address
From
Day Month Year
To
Day Month Year
Why were they there?
Full Address
From
Day Month Year
To
Day Month Year
Why were they there?
Full Address
From
Day Month Year
To
Day Month Year
Why were they there?
Full Address
From
Day Month Year
To
Day Month Year
Why were they there?
15SFW/DSA1F/2122/EN
!
Section 4 - about your course and your university
or college
In this section, please give details of your first choice university or
college and course.
a
University or college details
University or college name and address
Postcode
b
Course details
Course name
If you are following a combined studies or modular course, please list all
subjects being studied
Qualification you expect
to gain (e.g. BSc Physics)
Course start date
Month Year
Course end date
Month Year
Course length (years)
Year of course
Foundation
First year
Second year
Third year
Fourth year
Other (give details)
Are you a direct
entrant?
Yes No
16 SFW/DSA1F/2122/EN
If the course is franchised to another university/college, give the address of the
other university or college
Postcode
Continued
Section 4 - about your course and your university
or college
Continued
17SFW/DSA1F/2122/EN
Section 5 - your university or college
Please ask your university or college to complete this section.
If you do not want to tell your university or college about your disability, long-term
health condition, mental health condition, specific learning difficulty or autism
spectrum disorder, then please read section 5 notes for further instructions and
then go to section 6.
To be completed by the Student’s university or college.
SLC or UCAS university or college code
Part-time undergraduate students
Student’s course start date is on or after 1 September 2014
I confirm to the best of my knowledge and belief that:
• The student named in section 1 is studying or applying for the course named in
section 4 and plans to study at a rate of at least 25% in this academic year; and
• The student’s rate of study is
%
of the equivalent full-time course.
Student started their course before 1 September 2014
I confirm to the best of my knowledge and belief that:
• the student named in section 1 is studying or applying for the course named
in section 4 and plans to complete the course at an average rate of study of at
least 50% of that needed to complete the course, or an equivalent course, on a
full-time basis; and
• The student’s rate of study is of the equivalent
%
full-time course.
Example
The student is studying a part-time course over a six year period but would study
for three years if he or she was on an equivalent full-time course. The rate of
study is 50%.
18 SFW/DSA1F/2122/EN
Section 5 - your university or college
Continued
Full-time undergraduate students, (who are not applying for other
finance) and full-time undergraduate distance learning students
I confirm to the best of my knowledge and belief that:
• the student named in section 1 is studying or applying for the course named in
section 4; and
• the student named in section 1 plans to complete the course on a full-time basis
by distance learning methods.
Part-time postgraduate students
Student started their course before 1st September 2014
I confirm to the best of my knowledge and belief that the student named in
section 1 is studying or applying for a part-time postgraduate course which will
not take more than twice as long to complete as an equivalent full-time course.
Student started their course on or after 1st September 2014
I confirm to the best of my knowledge and belief that the student named in section
1 is studying or applying for a part-time postgraduate course which will take no
more than four times as long to complete as an equivalent full-time course.
All postgraduate students
I confirm to the best of my knowledge and belief that:
• the student named in section 1 is studying or applying for the course named in
section 4;
• this course has a usual entry qualification of a first degree or higher; and
• the student will not receive an award from their institution (not including any
payment from the institution’s hardship fund) to meet the extra course-related costs
they have to pay because of their disability.
Your full name (in BLOCK CAPITALS)
Your signature
University or college stamp
Position
Your phone number (including area code)
Your email address
Date
Day Month Year
19SFW/DSA1F/2122/EN
Section 6 - DSA information and evidence
/
/
/
/
/
/
/
/
!
Your disability, mental health condition, long-term health condition, specific
learning difficulty or autism spectrum disorder
You are defined as having a disability under the Equality Act 2010 if you
have a physical or mental impairment which has a substantial and long-term
adverse affect on your ability to carry out normal day-to-day activities.
a
Please give full details of the nature of your disability, long-term health
condition, mental health condition, specific learning difficulty or autism spectrum
disorder. If you need extra space use the additional notes page at the back of
this form.
b Is this your first application for Disabled Students’ Allowance (DSA)?
Yes
No
if ‘Yes’ go to section 7
If ‘No’, please provide the following details of each previous DSA funding
application you have made.
Date of application
Day
Month
Year
Funding authority applied to
If you cannot provide evidence of each previous DSA funding application you have
made, please provide full details of the funding you received in the box below.
We may contact the relevant funding authorities for further information.
20 SFW/DSA1F/2122/EN
!
Section 7 - your consent
Your consent to DSA arrangements
Please tick the boxes below if you consent to the following DSA
arrangements.
You have the right to withdraw your consent to us processing your personal
information in relation to this application form. To withdraw your consent, please
contact us.
I agree that Student Finance Wales, the disability adviser at my university or
college, and my DSA Needs Assessor may exchange information about my
application for DSA where this is necessary to make sure I get the help I need.
I agree that Student Finance Wales equipment suppliers and non-medical help
suppliers may exchange information about my application for DSA where this
is necessary to make sure I get the help I need.
I agree that Student Finance Wales can directly pay the needs assessment
centre and suppliers of equipment and support.
Section 8 - your bank or building society account details
UK bank or building society account details
Where possible we will pay suppliers of your equipment or support services
directly. However, please complete the section below so that we can pay you if
we need to. You do not need to provide these details if you have already given
them to us.
The account must be in your own name and be able to accept direct
credits.
Sort code
Account number
Building society roll number (if applicable)
21SFW/DSA1F/2122/EN
Terms and Conditions
These terms and conditions (“terms”) and applicable legislation apply to all of the
student finance available to students for the academic year 2021/22.
I understand that I must read the specific terms about the student finance
products available because they will affect me if I apply for them at any time in this
academic year.
I understand that my application for student finance may be delayed unless I sign
and date these terms.
Loan Contract
1. I confirm I have read and understood these terms and A Guide to Terms
and Conditions available at www.studentfinancewales.co.uk/terms-and-
conditions.
2. I confirm that to the best of my knowledge and belief, the information I have
provided is true and complete. If it is not, I understand that I may not receive
student finance, any support I have had may be withdrawn and I could be
prosecuted.
3. I understand that student finance is provided to me by the Welsh Ministers
(the “Lender”) which includes any persons acting on their behalf and any
replacement(s) under section 23(4) of the Teaching and Higher Education Act
1998 as amended or replaced from time to time (the “Act”).
4. I understand these terms, the Act and the regulations made under section 22 of
the Act will apply to any student finance provided to me by the Lender.
5. I understand that “student finance” in these terms means financial support by way
of grant(s) and/or loan(s) made by the Lender under the regulations.
6. I understand that the Student Loans Company Limited (“SLC”) carries out certain
functions on behalf of the Lender.
My Obligations
7. I understand that if I have:
(i) reached the age of 18 years; and
(ii) have entered into agreement(s) for a loan under section 22 of the Act before I
reached the age of 18 years,
I am agreeing to “ratify” any and all such student loans by signing these terms.
This means that I confirm I entered into agreement(s) with the Lender and agree
to the terms of any such previous agreement(s). If I have reached the age of 18
and refuse to “ratify” any previous agreement(s), I understand that I will not be
eligible to get any further student finance under the regulations.
8. I agree to give SLC any information they need in support of this application for
student finance and/or to seek repayment.
9. I agree to tell SLC immediately if my circumstances change in any way that might
affect my entitlement to student finance. I understand that if I do not do this I
may not get any further payments and I may have to repay the student finance
22 SFW/DSA1F/2122/EN
I have already received. I agree that from the date I submit my student finance
application until my loan(s), together with all and any interest, penalties and
charges which apply, is fully repaid I must tell SLC about any changes in my
personal details (including my National Insurance number) and contact details I
have provided.
10. I agree that if I get an overpayment of student finance, I need to repay this in full
and that any overpayment may be taken from any future entitlement to student
finance.
11. I agree that I will repay the Lender any loan(s), together with all and any interest,
penalties and charges which apply. I understand that this repayment will be due
by me to the Lender as a debt. If I breach any of the terms of my loan, I agree to
pay any charges and penalties which apply under the Act and the regulations.
I understand that I will repay my loan(s) through the United Kingdom (“UK”) tax
system and/or I may repay SLC directly. If I live abroad, I will repay my loan(s)
to SLC directly.
12. I agree that any loan(s) made to me in accordance with the regulations once my
application is accepted by the Lender is a/are contract(s) between me and the
Lender. I understand that I am liable for my loan(s) and will be charged interest
from the first payment of the loan advance by the Lender.
13. I agree to tell SLC if I leave the UK to live outside the UK or if for any other
reason I am outside the UK tax system for more than three months.
Legal Action and Applicable Law
14. In the event of any legal action, I agree that the laws of England and Wales will
apply and that the courts of that part of the UK will hear any legal action. If my
address is outside the UK the laws of the part of the UK where my education
provider is situated will apply and the courts of that part of the UK will hear any
legal action. I agree that the Lender has the right to take legal action against me
in any other court with jurisdiction.
Sharing Information
15. If I am in breach of these terms and/or the regulations I agree that the Lender
may share information held about me and my account with third parties,
including the government or a government agency of another country, who may
help to locate me and/or help take action to recover any payments I owe.
16. I confirm where I have provided any personal information about any other
person in my student finance application, I have done so with their consent.
17. I understand that SLC will process my personal data in line with the Privacy
Notice available at www.studentfinancewales.co.uk/privacy-notice which
may be updated from time to time.
Disabled Students’ Allowance (“DSA”)
This section applies if I apply for DSA this academic year.
18. I understand that any equipment I receive through DSA must be used for my
course of study and that I am responsible for paying any repair costs.
19. I understand that if I consent to SLC sourcing my equipment and support, SLC
can pay the suppliers of any approved equipment and support directly.
20. I understand that with my consent, SLC can make payment to the needs
assessment centre on my behalf.
23SFW/DSA1F/2122/EN
21. I understand that with my consent, SLC can make a direct payment on my
behalf to third parties providing any other approved service or support to me.
22. If I do not agree to SLC paying the suppliers of equipment, support or other
services on my behalf, I understand that I will be responsible for meeting the
costs of any approved equipment, support or other services out of my DSA
allowance. SLC reserves the right to request evidence of receipt of equipment,
support or other services in relation to my DSA.
Childcare Grant (“CCG”)
This section applies if I apply for CCG this academic year.
23. I understand that if I do not provide the evidence of childcare costs within the
timescales set, I may lose my entitlement. If my childcare costs are different
from the estimates I have provided, further payments of my CCG may increase
or decrease accordingly. If no further CCG payments are due to be paid to me, I
may be liable to repay any difference.
24. I understand that if I do not take up my childcare, or if I change to a childcare
provider who is not registered or approved, I will have to pay back any
overpayment.
25. I confirm that neither I nor my husband, wife, civil partner or cohabiting partner
have chosen to receive support for childcare from:
(i) the childcare element of Working Tax Credit;
(ii) the childcare element of Universal Credit;
(iii) Tax-Free Childcare; and/or
(iv) the NHS Bursary Childcare Allowance;
and I agree to tell SLC immediately if I or my husband, wife, civil partner or
cohabiting partner does receive this support. I understand that SLC may share
my personal data with HMRC to check whether I get childcare support.
Customer Reference Number
x
Your full name
(in BLOCK CAPITALS)
Your signature
(in ink
)
Today’s date
Day Month Year
24 SFW/DSA1F/2122/EN
Checklist
Before returning this form, please make sure you have done the following:
Signed and dated the Terms and Conditions.
Enclosed all the evidence items as requested in the DSA1 notes. Any original
evidence you send will be returned to you as soon as possible.
If applicable, your university or college has completed section 5.
Remember to pay the correct postage.
Once your form is fully complete and the Terms and Conditions have been signed
and dated, you should return it to:
Student Finance Wales
PO Box 211
Llandudno Junction
LL30 9FU
25SFW/DSA1F/2122/EN
Additional notes
If you are providing extra information please clearly mark what section and
question number the information is about.
26 SFW/DSA1F/2122/EN
Additional notes
If you are providing extra information please clearly mark what section and
question number the information is about.
27SFW/DSA1F/2122/EN
Additional notes
If you are providing extra information please clearly mark what section and
question number the information is about.
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DSA1 202122 Application for Disabled Students Allowance (DSA) (London Institute of Management and Technology)

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Completed 20 July 2021

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