Ema Wales Standard Application Form

8/6/2019 Ema Wales Standard Application Form

http://slidepdf.com/reader/full/ema-wales-standard-application-form 1/24

SFW/EMA/F/V1011

Education Maintenance Allowance

Application Form for

EMA in 2010/11

student finance wales

www.studentfinancewales.co.uk/EMA

E M A



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EMA

1Completethe form

2Return the

form

3Receive your award letter

Use this form to apply for EMA for 2010/11 if you intend to study at a school or college in

Wales from September 2010. If you are not sure if you will continue studying, or where you

will study, you can still apply.

You need to:

• Complete Sections A to H of the form.• Make sure your parent(s)/guardian(s) or partner complete Sections I and J if they need

to. This will depend on your answers in Section E.

• Send original evidence to support your application. Any evidence needed is indicated

by this icon and details about the evidence can be found in the guidance notes.

• Sign the Student Declaration on page 7.

Don’t forget:

• To tell us your bank details in Section F. We can’t pay you if we don’t know them.

• Read the guidance notes if you need any help with the questions on the form.

• Call us on 0845 602 8845 or visit our website at www.studentfinancewales.co.uk/EMA

if you need any further help.

You need to:

• Send your completed form to us with all the evidence we need by June 2010 to make

sure your EMA entitlement is agreed and in place well in advance of your first 2010/11

term.

• Make sure all the evidence we need is sent with the form. You can send your completed

form to us even if you are still waiting for evidence. Once you have the remaining

evidence you can send it to us separately at a later date.

• Pay the correct postage. We recommend you also get proof of postage in case there

are any delivery problems.

Don’t forget:

• To get the envelope weighed before you return it so that you pay the correct postage.

If you don’t your EMA payments may be delayed.

• To get payments backdated you need to return the form within 8 weeks of starting your

course.

You will receive a letter when we receive your application form. If you do not receive a

letter within two weeks of sending your form, please contact us.

We will:

• Send you an award letter telling you how much your weekly EMA entitlement is for

academic year 2010/11.

Don’t forget:

• To keep your award letter because your school or college may ask to see it when you

sign your Learning Agreement with them for academic year 2010/11.

• You need to sign a Learning Agreement before you will receive any EMA payments.

Send your form back to us as soon as possible to make sure your payments are made on

time. If you don’t, there may be a delay to your payments. The latest date you can return your

form and any information and evidence we have asked for is 31 August 2011. If you miss this finaldeadline you will not get any EMA payments for academic year 2010/11.

We will only send you an award letter when your application is fully complete.

This means we must have all of the information and evidence required. If we need

any further information or evidence to complete our assessment, we will contact you.

We can only work out your EMA entitlement if you complete all relevant parts of the

application form, send the evidence we need and sign the Student Declaration on page 7.

It’s time to apply for EMA for academic year 2010/11

Applying is as easy as 1, 2, 3!

!

!

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SECTION A – YOUR PERSONAL DETAILS

If you are an existing EMA student, please provide yourCustomer Reference Number:

Q1. Title Mr Mrs Miss Other

First name(s)

Surname/Family name

Sex Male Female

Date of birth

In which town or city were you born?

Q2. Home address

Postcode

Home telephone number

Mobile telephone number

Email address

Security Details

Q3a. Please provide a ‘Secret Answer’.It is important you make your Secret Answer easy to remember as we will ask you toconfirm this whenever you call us.

Q3b. Please provide a ‘hint’ question to remind you of your Secret Answer.

For example, if you chose ‘Superman’ as your Secret Answer then your ‘hint’ question couldbe ‘What is the name of my favourite superhero?’

If you ever forget your Secret Answer we will ask you this ‘hint’ question to help youremember it.

YEARMONTHDAY

INTERNAL REFERENCE NUMBER: (For internal use only)

SECTION B – YOUR SCHOOL OR COLLEGE DETAILS

Please enter the details of the school or college where you intend to study from 1 September 2010.If you are unsure where you will be studying from September 2010, please enter the details of theschool or college you are currently attending.

Q1. Name of school or college

Campus

Q2. School or college address

Postcode



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SECTION C – YOUR NATIONALITY AND RESIDENCY DETAILS

Q1. Which best describes you? Tick one box from a to h.

Once you have ticked a box follow the arrows, answer any relevant questions and read theinstructions on what to do next.

a. I am a UK national

OR

I have ‘Settled Status’ or'Indefinite Leave to Enter orRemain' in the UK

b. I am an EUnational

c. I have, or my familymember* has, beengranted ‘Leave toenter or remain’ in theUK

I have been ordinarilyresident in:

• the UK

for 3 years prior to thefirst day of my course

Yes No

I have been ordinarily resident in:

• the UK

• the EU/EEA

• Switzerland

for 3 years prior to the first day ofmy course

Yes No

* your family member means your husband, wife, civil partner, parent or step-parent.

go to section E go to section D go to section E

YEARMONTHDAY

From

YEARMONTHDAY

To

First address:

Why were you there:

SECTION D – YOUR RESIDENCY HISTORY

Q1. Details of your residence for the three years before the start of the first academic year ofyour course.

You are NOTeligible forEMA

Tick Tick Tick

I have been ordinarilyresident in:

• the UK

for 3 years prior to thefirst day of my course

Yes No

go to section E

Go to section Cof the notes

go to section E



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SECTION C – YOUR NATIONALITY AND RESIDENCY DETAILS

d. I am a childof a Swissnational

e. I am, or my familymember* is, an EEAor Swiss nationalwho is working/ hasworked or is lookingfor work in the UK

f. I am a child of aTurkish nationalwho isworking/hasworked in the UK

g. I have, or myfamily member*has, refugeestatus in the UKOR I have EUtemporaryprotection statusin the UK

h. Noneofthese

I have been ordinarily resident in:

• the UK

• the EU/EEA

• Switzerland


I have been ordinarily resident in:• the UK

• the EU/EEA

• Turkey

• Switzerland





Yes No Yes No

go to section E go to section E go to section E

SECTION D – YOUR RESIDENCY HISTORY

YEARMONTHDAY

From

YEARMONTHDAY

To

Second address:

Why were you there:

Tick Tick Tick Tick Tick



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SECTION F – YOUR BANK OR BUILDING SOCIETY ACCOUNT DETAILS

• You must provide us with details of an account that accepts direct credits.

• Enter the full name of the account holder, as it is written on your bank or building society

statement or card.

• You can find your sort code and account number on your bank or building society statements.• Your building society roll number can contain up to 18 letters and numbers, for example,

JOHNSO12345678. Some building societies ask you to complete this field to let them make

automatic payments into your account. If you are not sure of your roll number ask your building

society for advice.

• If you do not complete this section correctly, your EMA award may be delayed.

If you have any exceptional circumstances which prevent you from opening a bank or

building society account in your own name please tick here.

Name of account holder

Name of bank or building society

Sort code

Account number

Building society roll number(if applicable)

- -

SECTION E –YOUR INDEPENDENCE DETAILS

This section helps to decide whether you are a dependent or an independent student, and

therefore, whose income needs to be taken into account when assessing your entitlement to

financial support.

If you answer ‘Yes’ to ANY of the questions below you may be considered independent.

If you answer ‘No’ to ALL of the questions below you are considered dependent.

Q1. Are you estranged from your parent(s)/guardian(s)?

Q2. Are you living under Local Authority care?

(for example, with foster parents)

Q3. Do you receive Income Support or Income Based

Employment and Support Allowance in your own name?

Q4. Are you responsible for a child of your own?

Q5. Are you currently a Young Person in custody/detention

within the Youth Justice System?

if ‘Yes’ go to Q3

Yes No

Yes No

Yes No

Yes No

Yes No



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f i n a n c e w a l e s SECTION I – YOUR HOUSEHOLD’S FINANCIAL DETAILS

This section should be completed by:• the student’s parent(s)/guardian(s) if the student is dependent.

• the student and their wife, husband, civil partner or partner (if applicable) if the student is:- estranged from their parent(s)/guardian(s) and- NOT living under Local Authority care and- NOT in receipt of Income Support or Income Based Employment and Support Allowance.

You must answer every question, entering the amount of income received. If you did notearn/receive any of the income types, you must enter £0.00 on the application form.It is essential that you provide accurate and complete income details. If you do not, it may preventthe student from receiving their full EMA entitlement.

Q1. Relationship to applicant

First name

Surname/Family name

Benefit Income

Q2. If either Person 1 or Person 2 is in receipt of Income Support

or Income Based Employment and Support Allowance tick here:

Q3. Has your household been issued with a Tax Credit Award

Notification for tax year 2009-10 other than version 'R'? Yes No

If 'Yes', enter your total annual household income as it

appears on your Tax Credit Award Notification:

Employment Income

Q4. Please provide information for tax year 2009-10:

Salaries and wages

Self-employment income

Taxable Social Security Benefits

Other income

Q5. What is your total annual income?

Person 1 Person 2

£

£ £

£ £

£ £

£ £

£ £

£ £

£ £

Person 1 Person 2

if 'Yes', enter an

amount and go toSection J

if ticked, go straight

to Section J



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Person 1 Person 2

Private pension contributions

Additional Voluntary

Contributions (AVCs)

Wages for domestic helpbecause of incapacity

Any other expensesconnected with employment

TOTAL DEDUCTIONS

TOTAL INCOME

(This is your Q5 TOTAL minus Q6

TOTAL DEDUCTIONS)

Q6.

Q7.

£

£

£

£

£

£

£

£

£

£

£

£


c e w al e s

Deductions

SECTION I – YOUR HOUSEHOLD’S FINANCIAL DETAILS



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f i n a n c e w a l e s SECTION J – DECLARATION FOR PERSON(S) NAMED IN SECTION I

Please read the following declaration. We will not be able to process this application for

EMA unless you sign and date this declaration.

Before signing and returning the completed form, you should read the Data Protection Act within

the EMA guidance notes that accompany this form. This statement sets out who will use the

information provided on this application form and what they will use it for.

• I confirm that the information I have given on this form is correct and complete to the best of my

knowledge and belief.

• I understand that any attempt to dishonestly obtain EMA shall be treated as fraud and may result in

criminal and/or civil proceedings against me.

Person 1

Your full name (in BLOCK CAPITALS):

Your signature:

Date:

YEARMONTHDAY

Person 2

Your full name (in BLOCK CAPITALS):

Your signature:

Date:

YEARMONTHDAY



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EQUAL OPPORTUNITIES MONITORING

VOLUNTARY QUESTIONNAIRE

The following questions are voluntary - you do not have to answer them. Whether you answer them or

not will not affect your application for an EMA. If you do answer, the information may be used to help

the Welsh Assembly Government develop its policies in the future.

Q1. Do you consider yourself to have a disability? Yes No

Q2. What do you consider your nationality identity to be?(Choose as many or as few as apply).

Welsh

Irish

English

British

Scottish

Other

Q3. Choose ONE section from A to E, then tick the appropriate box to indicate your ethnic group.

A White D Black or Black British

British Caribbean

Any other white background African

Any other black background

B Mixed E Chinese or other ethnic group

White and Black Caribbean Chinese

White and Black African Any other

White and Asian

Any other mixed background

C Asian or Asian British

Indian

Pakistani

Bangladeshi

Any other Asian background

PLEASE RETURN THIS COMPLETED QUESTIONNAIRE WITH YOUR APPLICATION FORM



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Use the checklist below to make sure you have correctlycompleted this form before your send it to us!

Have you:

• Completed all the questions relevant to you in Sections A to H?

• Attached all the original documentary evidence we need with this form?

• Told us your bank details on page 6?

• Signed and dated the Student Declaration on page 7?

• Indicated whether you consent to us providing details of the progress of yourapplication and award to your parent(s)/guardian(s) or partner on page 7?

Checklist for Parent(s)/Guardian(s) or Partner (Person 1 & 2):So that we can assess this application have you:

• Completed and checked Sections I and J?

• Provided the correct total household income on page 9?

• Attached your household’s Tax Credit Award Notification (if applicable)?

• Attached evidence to support the statement of household income, if youare not in receipt of a Tax Credit Award Notification?

• Signed and dated the Declaration(s) on page 10?

Returning the formIt is recommended that you send the completed form to us with the evidence we need by June 2010to make sure your EMA entitlement is agreed and in place well in advance of your first 2010/11 term.

• To get backdated payments you need to return the form within 8 weeks of starting your course.

Any missing information or documentation may result in late payment of your EMA award.However, please do not delay sending in your application form if you are having difficultyproviding this evidence.

At the very latest, application forms, information and evidence must be received by 31 August 2011or you will not get any EMA payments for academic year 2010/11.

Postage• Check you have paid the correct postage before you post your EMA application. The

application form and envelope should be weighed and the correct postage paid or this will delaywhen we receive your application. This could mean a delay to the start of your payments.

• We recommend that you get proof of postage when returning this form in case of any

delivery problems. This is because any delay in receiving your application form could delay thestart of your payments.

Now send us your formOnce you have completed the checklist above, send your completed form and original supportingevidence, using the envelope provided, to:

EMA Wales Customer Services

Admail 3888

Cardiff

CF11 0ZY

If you have not received a letter from us within two weeks of sending your application form, oryou have any other queries, please contact us on 0845 602 8845.

If you have hearing difficulties, and wish to speak to an advisor using a minicom device, pleasecontact us on 0845 603 1693.

!

Tick

Tick

Tick

Tick

Tick

Tick

Tick

Tick

Tick

Tick



SFW/EMA/F/V1011

Lwfans Cynhaliaeth Addysg

Ffurflen Gais am

LCA yn 2010/11

cyllid myfyrwyr cymru

www.cyllidmyfyrwyrcymru.co.uk/LCA

L C A



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ADRAN A – EICH MANYLION PERSONOLOs ydych yn fyfyriwr sy’n cael LCA yn barod,nodwch eich Cyfeirnod Cwsmer:

C1. Teitl Mr Mrs Miss Arall

Enw(au) cyntaf

Cyfenw/Enw teuluol

Rhyw Gwryw Benyw

Dyddiad geni

Ym mha dref neu ddinas y cawsoch eich geni?

C2. Cyfeiriad cartref

Côd post

Rhif ffôn cartref

Rhif ffôn symudol

Cyfeiriad e-bost

Manylion DiogelwchC3a. A fyddech gystal â nodi ‘Ateb Cyfrinachol’.

Mae’n bwysig bod eich Ateb Cyfrinachol yn un hawdd i’w gofio oherwydd byddwn yngofyn i chi gadarnhau hwn bob tro y byddwch yn ein ffonio.

C3b. A fyddech gystal â nodi cwestiwn ‘awgrymiadol’ er mwyn eich atgoffa o’ch Ateb Cyfrinachol.

Er enghraifft, os byddwch yn dewis ‘Superman’ fel eich Ateb Cyfrinachol, gallech nodi ‘Bethyw enw fy hoff arwr i?’ fel eich cwestiwn ‘awgrymiadol’.

Os byddwch yn anghofio eich Ateb Cyfrinachol, byddwn yn gofyn y cwestiwn‘awgrymiadol’ hwn i chi er mwyn eich helpu i’w gofio.

BLWYDDYNMISDYDD

CYFEIRNOD MEWNOL: (At ddefnydd mewnol yn unig)

ADRAN B – MANYLION EICH YSGOL NEU GOLEGDylech nodi manylion yr ysgol neu’r coleg lle’r ydych yn bwriadu astudio o 1 Medi 2010.Os nad ydych yn siŵr ble y byddwch yn astudio o fis Medi 2010, dylech nodi manylion yr ysgol neu’r coleg yr ydych yn ei mynychu/fynychu ar hyn o bryd.

C1. Enw’r ysgol neu’r coleg

Campws

C2. Cyfeiriad yr ysgol neu'r coleg

Côd post

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y f y r w y r c y m r u ADRAN C – EICH MANYLION CENEDLIGRWYDD A PHRESWYLIO

C1. Pa un sy'n eich disgrifio chi orau? Ticiwch un blwch o a i h.

Ar ôl i chi roi tic mewn blwch, dilynwch y saethau, atebwch unrhyw gwestiynau perthnasol adarllenwch y cyfarwyddiadau am yr hyn i'w wneud nesaf.

a. Rydw i'n wladolyn y DU

NEU

Rydw i wedi sicrhau ‘StatwsPreswylydd Sefydlog’ neurhoddwyd 'Caniatâd Mynediadneu Aros am amser Amhenodol'i mi yn y DU

b. Rydw i'nwladolynyr UE

c. Rydw i, neu aelod o'mteulu*, wedi sicrhau'Caniatâd mynediadneu aros' yn y DU

Rydw i wedi bod ynpreswylio fel arfer yn:

• y DU

am 3 blynedd cyndiwrnod cyntaf fy nghwrs

Rydw i wedi bod yn preswylio felarfer yn:

• y DU• yr UE/AEE• y Swistir

am 3 blynedd cyn diwrnod cyntaf fy nghwrs

* mae aelod o'ch teulu yn golygu eich gŵr, eich gwraig, eich partner sifil, eich rhiant neu'ch llys-riant.

ewch i adran E ewch i adran D ewch i adran E

BLWYDDYNMISDYDD

Rhwng

BLWYDDYNMISDYDD

A

Cyfeiriad cyntaf:

Pam oeddech chi yno:

ADRAN D – HANES EICH MANYLION PRESWYLIO

C1. Eich manylion preswylio yn ystod y tair blynedd cyn dechrau blwyddyn academaidd gyntaf eich cwrs.

NID ydychyn gymwys igael LCA

TiciwchTiciwchTiciwch

Ydw ydwNac

Ydw ydwNac

Rydw i wedi bod ynpreswylio fel arfer yn:

• y DU

am 3 blynedd cyndiwrnod cyntaf fy nghwrs

ewch i adran E ewch i adran E

Ydw ydwNac

Ewch i Adran Cy nodiadau



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ADRAN C – EICH MANYLION CENEDLIGRWYDD A PHRESWYLIO

d. Rydw i'nblentyngwladolyny Swistir

e. Rydw i, neu aelodo'm teulu*, ynwladolyn yr AEEneu'r Swistir sy’ngweithio/wedi bodyn gweithio neusy’n chwilio amwaith yn y DU

f. Rydw i'n blentyngwladolynTwrci sy'ngweithio/wedibod yn gweithioyn y DU

g.Rydw i, neu aelodo'm teulu*, wedisicrhau statwsffoadur yn y DUNEU rydw i wedisicrhau statwsamddiffyn drosdro yr UEyn y DU

h. Dim uno'r rhain

Rydw i wedi bod yn preswylio fel arfer yn:

• y DU• yr UE/AEE• y Swistir

am 3 blynedd cyn diwrnod cyntaf fynghwrs

Rydw i wedi bod yn preswylio fel arfer yn:

• y DU• yr UE/AEE• Twrci• y Swistir

am 3 blynedd cyn diwrnod cyntaf fynghwrs



NID ydychyn gymwys igael LCAewch i adran E ewch i adran E ewch i adran E

ADRAN D – HANES EICH MANYLION PRESWYLIO

BLWYDDYNMISDYDD

Rhwng

BLWYDDYNMISDYDD

A

Ail gyfeiriad:

Pam oeddech chi yno:

Ticiwch Ticiwch Ticiwch Ticiwch Ticiwch

Ydw ydwNac

Ydw ydwNac



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ADRAN F – MANYLION EICH CYFRIF BANC NEU GYMDEITHAS ADEILADU

• Rhaid i chi ddarparu manylion cyfrif sy’n fodlon derbyn credydau uniongyrchol.

• Nodwch enw llawn deiliad y cyfrif, yn unol â’r hyn a nodir ar eich datganiad neu’ch cerdyn banc

neu gymdeithas adeiladu.• Gallwch weld eich côd didoli a rhif eich cyfrif ar eich datganiadau banc neu gymdeithas adeiladu.

• Gall eich rhif rhôl cymdeithas adeiladu gynnwys hyd at 18 o lythrennau a rhifau, er enghraifft,JOHNSO12345678. Bydd rhai cymdeithasau adeiladu yn gofyn i chi nodi’r rhif hwn er mwyncaniatáu iddynt wneud taliadau awtomatig i’ch cyfrif. Os nad ydych yn gwybod eich rhif rhôl,gofynnwch i’ch cymdeithas adeiladu am gyngor.

• Os na fyddwch yn llenwi’r adran hon yn gywir, efallai y bydd eich dyfarniad LCA yn cael ei oedi.

Os ydych yn wynebu unrhyw amgylchiadau arbennig sy’n eich atal rhag agor cyfrif banc neu

gymdeithas adeiladu yn eich enw chi, ticiwch yma.

Enw deiliad y cyfrif

Enw’r banc neu’r gymdeithas adeiladu

Côd didoli

Rhif y cyfrif

Rhif rhôl cymdeithas adeiladu

(os yw’n berthnasol)

- -

ADRAN E – MANYLION AM EICH ANNIBYNIAETH

Mae’r adran hon yn helpu i benderfynu a ydych yn fyfyriwr dibynnol neu annibynnol, ac felly,incwm pwy y bydd angen ei ystyried wrth asesu’ch hawl i gael cymorth ariannol.

Os byddwch yn ateb ‘Ydw’ i UNRHYW UN o’r cwestiynau isod, efallai y byddwch yn cael eichystyried yn annibynnol.

Os byddwch yn ateb ‘Nac ydw’ i’r HOLL gwestiynau isod, fe’ch ystyrir yn ddibynnol.

C1. A ydych wedi ymbellhau o’chrhiant(rhieni)/gwarcheidwad(gwarcheidwaid)?

C2. A ydych yn byw dan ofal Awdurdod Lleol?(er enghraifft, gyda rhieni maeth)

C3. A ydych yn cael Cymhorthdal Incwm neu Lwfans Cyflogaetha Chymorth wedi’i Seilio ar Incwm yn eich enw chi?

C4. A ydych yn gyfrifol am eich plentyn eich hun?C5. A ydych yn Berson Ifanc yn y ddalfa/yng nghadw'r

System Cyfiawnder Ieuenctid ar hyn o bryd?

os ‘Ydw’ewch i C3

Ydw ydwNac

Ydw ydwNac

Ydw ydwNac

Ydw ydw

Nac

Ydw ydwNac



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Os ydych yn fyfyriwr dibynnol,dylech roi’r ffurflen gais hon

i’ch rhiant(rhieni)/gwarcheidwad(gwarcheidwaid)er mwyn iddynt lenwi Adrannau I a J.

Myfyriwr Dibynnol

Ar gyfer yr holl fyfyrwyr annibynnol eraill, rydych

wedi gorffen llenwi'r ffurflenyn barod. Ewch i dudalen 11.

Os ydych wedi ateb ‘Ydw’yn C1 a ‘Nac ydw’ yn C3

yn Adran E, rhaid i chia’ch partner (pan fohynny’n berthnasol),lenwi Adrannau I a J.

Myfyriwr AnnibynnolMyfyriwr Annibynnol

ADRAN G – CANIATÂD I RANNU

Bydd y wybodaeth y byddwch yn ei ddarparu yn y ffurflen hon yn cael ei ddarparu i LywodraethCynulliad Cymru, y Cwmni Benthyciadau Myfyrwyr (SLC) neu unrhyw sefydliadau eraill a ddefnyddir gan Lywodraeth Cynulliad Cymru at ddibenion gweinyddu'ch cais am LCA. Gallai'r cyrff hynddefnyddio'r wybodaeth hon at ddibenion cynnal ymchwil y farchnad.

Os nad ydych yn rhoi eich caniatâd i’ch gwybodaeth gael ei ddefnyddio er mwyn cynnal ymchwil yfarchnad, ticiwch yma.

Gwybodaeth bwysig os ydych yn byw gyda’ch rhiant(rhieni)/gwarcheidwad(gwarcheidwaid)neu bartner:

Mae’n bwysig ein bod yn gwybod a fyddwch yn gadael i ni drafod eich cais a’ch dyfarniad gyda’chrhiant(rhieni)/gwarcheidwad(gwarcheidwaid) neu’ch partner. Ni allwn roi gwybodaeth am eich caisneu’ch dyfarniad i unrhyw un heb i chi gytuno.

• Rydw i’n rhoi fy nghaniatâd i Dîm Gwasanaethau Cwsmeriaid LCA Cymrui ddarparu manylion am gynnydd fy nghais a’m dyfarniad i’r unigolyn aenwyd fel Unigolyn 1 yn Adran l y ffurflen gais hon.

a, phan fo hynny’n briodol

• Rydw i’n rhoi fy nghaniatâd i Dîm Gwasanaethau Cwsmeriaid LCA Cymrui ddarparu manylion am gynnydd fy nghais a’m dyfarniad i’r unigolyn aenwyd fel Unigolyn 2 yn Adran l y ffurflen gais hon.

ADRAN H – DATGANIAD Y MYFYRIWR

A fyddech gystal â darllen y datganiad canlynol. Ni fyddwn yn gallu prosesu’ch cais am LCAoni bai eich bod yn llofnodi ac yn dyddio’r datganiad hwn.

Cyn llofnodi a dychwelyd y ffurflen ar ôl ei llenwi, dylech ddarllen y Datganiad Diogelu Data yn nodiadaucanllaw LCA a anfonwyd gyda’r ffurflen hon. Mae’r datganiad hwn yn nodi pwy fydd yn defnyddio’r wybodaeth a nodir yn y ffurflen gais hon a’r hyn y byddant yn defnyddio’r wybodaeth ar ei gyfer.

• Rydw i’n cadarnhau, hyd eithaf fy ngwybodaeth a’m cred, bod y wybodaeth a nodais yn y ffurflenhon yn gywir ac yn gyflawn.

• Rydw i’n cadarnhau fy mod wedi cyflwyno dogfennaeth ategol yn unol â’r nodiadau canllaw.

• Deallaf y bydd unrhyw ymgais i geisio sicrhau LCA mewn ffordd anonest yn cael ei thrin fel twyll acfe allai arwain at ddwyn achos troseddol a/neu sifil yn fy erbyn.

Enw llawn y myfyriwr (mewn PRIFLYTHRENNAU):

BLWYDDYNMISDYDDLlofnod y myfyriwr: Dyddiad:

Adrannau y bydd angen i chi eu llenwi nawr:

Ydw ydwNac

Ydw ydwNac



ADRAN I – MANYLION ARI ANNOL EICH CARTREF

Dylai’r canlynol lenwi’r adran hon:• rhiant(rhieni)/gwarcheidwad(gwarcheidwaid) y myfyriwr os yw’r myfyriwr yn ddibynnol.

• y myfyriwr a'i wraig, gŵr, partner sifil neu bartner (pan fo hynny’n berthnasol) os yw’r myfyriwr:- wedi ymbellhau o’u rhiant(rhieni)/gwarcheidwad(gwarcheidwaid) a- HEB fod yn byw dan ofal Awdurdod Lleol a- HEB fod yn cael Cymhorthdal Incwm neu Lwfans Cyflogaeth a Chymorth wedi’i Seilio ar Incwm.

Rhaid i chi ateb pob cwestiwn gan nodi cyfanswm yr incwm a gafwyd. Os na wnaethoch chiennill/derbyn unrhyw rai o’r mathau o incwm, rhaid i chi nodi £0.00 ar y ffurflen gais.Mae’n hanfodol eich bod yn darparu manylion cywir a chyflawn am eich incwm. Os na f yddwch yngwneud hynny, gallai hyn atal y myf yriwr rhag cael swm llawn LCA y mae ganddynt yr hawl i’w gael.

C1. Perthynas gyda’r ymgeisydd

Enw cyntaf

Cyfenw/Enw teuluol

Incwm gan Fudd-daliadau

C2. Os yw Unigolyn 1 neu Unigolyn 2 yn cael Cymhorthdal Incwm neu

Lwfans Cyflogaeth a Chymorth wedi’i Seilio ar Incwm, ticiwch yma:

C3. A yw’ch cartref wedi cael Hysbysiad Dyfarniad Credyd Treth

ar gyfer blwyddyn dreth 2009-10 ac eithrio fersiwn 'R'? Ydy ydy

Os 'Ydy', nodwch gyfanswm incwm blynyddol eich cartref fel y

mae’n ymddangos ar eich Hysbysiad Dyfarniad Credyd Treth:

Incwm gan Gyflogaeth

C4. A fyddech gystal â darparu gwybodaeth ar gyfer blwyddyn dreth 2009-10:

Cyflogau

Incwm hunangyflogedigBudd-daliadau Nawdd

Cymdeithasol Trethadwy

Incwm arall

C5. Beth yw cyfanswm eichincwm blynyddol?

8 SFW/EMA/F/V1011

c y l l i d m


Unigolyn 1 Unigolyn 2

£

£ £

£ £

£ £

£ £

£ £

£ £

£ £


os 'Ydy', nodwchswm ac ewch i Adran J

os ticiwyd, ewchyn syth i Adran J

Nac



9SFW/EMA/F/V1011


Cyfraniadau i bensiwn preifat

Cyfraniadau GwirfoddolYchwanegol (AVCs)

Cyflog am help domestigoherwydd analluogrwydd

Unrhyw dreuliau eraill sy’ngysylltiedig â chyflogaeth

CYFANSWM Y DIDYNIADAU

CYFANSWM YR INCWM(Hwn yw'ch CYFANSWM C5yn llai CYFANSWM YDIDYNIADAU yn C6)

C6.

C7.

£

£

£

£

£

£

£

£

£

£

£

£


yr c ymr u

Didyniadau

ADRAN I – MANYLION ARIANNOL EICH CARTREF



ADRAN J – DATGANIAD AR GYFER UNIGOLYN(UNIGOLION) A ENWIR YN ADRAN I

A fyddech gystal â darllen y datganiad canlynol. Ni fyddwn yn gallu prosesu’ch cais amLCA oni bai eich bod yn llofnodi ac yn dyddio’r datganiad hwn.

Cyn llofnodi a dychwelyd y ffurflen ar ôl ei llenwi, dylech ddarllen y Datganiad Diogelu Data yn ynodiadau canllaw LCA a anfonwyd gyda’r ffurflen hon. Mae’r datganiad hwn yn nodi pwy fydd yn

defnyddio’r wybodaeth a nodir yn y ffurflen gais hon a’r hyn y byddant yn defnyddio’r wybodaethar ei gyfer.

• Rydw i’n cadarnhau, hyd eithaf fy ngwybodaeth a’m cred, bod y wybodaeth a nodais yn y ffurflenhon yn gywir ac yn gyflawn.

• Deallaf y bydd unrhyw ymgais i sicrhau LCA mewn ffordd anonest yn cael ei thrin fel twyll ac feallai arwain at ddwyn achos troseddol a/neu sifil yn fy erbyn.

10 SFW/EMA/F/V1011

c y l l i d m


Unigolyn 1

Eich enw llawn (mewn PRIFLYTHRENNAU):

Eich llofnod:

Dyddiad:

BLWYDDYNMISDYDD

Unigolyn 2

Eich enw llawn (mewn PRIFLYTHRENNAU):

Eich llofnod:

Dyddiad:

BLWYDDYNMISDYDD



11SFW/EMA/F/V1011


yr c ymr u

HOLIADUR GWIRFODDOL MONITRO

CYFLE CYFARTAL

Mae’r cwestiynau canlynol yn gwestiynau gwirfoddol – nid oes yn rhaid i chi eu hateb. Ni fydd eichpenderfyniad i’w hateb neu beidio eu hateb yn effeithio ar eich cais am LCA. Os byddwch yn euhateb, efallai y defnyddir y wybodaeth i helpu Llywodraeth Cynulliad Cymru i ddatblygu ei pholisïauyn y dyfodol.

C1. A ydych yn ystyried bod gennych anabledd? Ydw Nac ydw

C2. Beth ydych chi’n ystyried yw eich cenedligrwydd?(Dewiswch gymaint neu gyn lleied ag sy’n berthnasol.)

Cymreig

Gwyddelig

Seisnig

Prydeinig

Albanaidd

Arall

C3. Dewiswch UN adran o A i E, yna ticiwch y blwch priodol i nodi’ch grŵp ethnig.

A Gwyn D Du neu Ddu Prydeinig

Prydeinig Caribïaidd

Unrhyw gefndir gwyn arall Affricanaidd

Unrhyw gefndir du arall

B Cymysg E Tsieineaidd neu grŵp ethnig arall

Gwyn a Du Caribïaidd Tsieineaidd

Gwyn a Du Affricanaidd Unrhyw gefndir arall

Gwyn ac Asiaidd

Unrhyw gefndir cymysg arall

C Asiaidd neu Asiaidd Prydeinig

Indiaidd

Pacistanaidd

Bangladeshaidd

Unrhyw gefndir Asiaidd arall

A FYDDECH GYSTAL Â DYCHWELYD YR HOLIADUR HWN, WEDI’I LENWI, GYDA’CH FFURFLEN GAIS

Ema Wales Standard Application Form

Documents

Transcript of Ema Wales Standard Application Form