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To be eligible:• youmustbeaged16to18yearsold.Youmusthavestartedyourcourse(orlearningprogramme)before

youturn19• youmustliveandstudyinEngland(seepage 8 oftheGuidanceNotes)• youmusthave‘settledstatus’intheUKandhavebeenordinarilyresidentinEnglandforthethreeyearspriortothe

coursestartdate.‘Settled’meanshavingeitherindefiniteleavetoenterorremain(ILE/R)orhavingtherightofabodeintheUK.BritishcitizensandcertainotherpeoplehavetherightofabodeintheUK

• yourcoursemustnotbeavailablelocallyi.e.withinreasonabledailytravellingdistance.‘Reasonabledailytravellingdistance’means:

-adailyreturnjourneywhichtakesundertwohoursonpublictransport;or -adistanceofunder15milesfromyourhometothecollege.

• youmustbestudyingonafull-timecourse.YourLearningProviderwillbeabletoconfirmthis• yourcoursemustbe16-19funded(yourLearningProviderwillbeabletoconfirmthis)andlastforaminimumof

10weeks• youmustbeabouttostudyforyour firstfullLevel2or firstfullLevel3qualification(inexceptionalcircumstances,

RSSmaysupportstudyforasecondLevel2orsecondLevel3qualification,oraLevel1qualification;youshouldspeaktoyourLearningProviderorcontacttheLearnerSupportServiceon0800 121 8989,ifyouwanttodiscusssupportofthiskind)

• youmustnotbegoingtooneofthespecialistcollegeslistedinAnnexAonpage 20oftheGuidanceNotes.IfyouareattendingoneofthesespecialistcollegesyouarenoteligibleforRSSandshouldtalktoyourLearningProvideraboutfundingthatmaybeavailablefromtheResidentialBursaryFund

• yourhouseholdincomeforthe2012-13taxyearmustbe£30,993orless.YourapplicationforRSSwillbeassessedonyourhouseholdincome.Thisisyourincomeandtheincomeoftheadult(s)whoaremainlyresponsibleforyoue.g.yourparent(s)oryourmaincarer(s)(seepage 9oftheGuidanceNotes)

• youmustnot beinreceiptofHousingBenefit.

Applying for the Residential Support Scheme (RSS) - An Introduction

Who can apply for the Residential Support Scheme?

Residential Support Scheme

IfyoureceivedRSSin2012/13butwillbeaged19before31August2013youwillnotbeeligibleforRSSsupportin2013/14eventhoughyourlearningprogrammemaybecontinuinginthisyear.InsteadyoushouldtalktoyourLearningProvideraboutsupportthatmaybeavailabletoyouthroughtheirResidentialAccessFundsforstudentsaged19orover.

Application for Academic Year 2013/14 26/08/13 - 31/08/14

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Checklist

Before you return your form to the Learner Support Service, make sure that:• youhaveansweredallrelevantquestionsinStudentDetails(PartA)• yourLearningProviderhascompletedtheDeclarationatquestionA13• allrelevantquestionsinIncomeDetails(PartB)havebeenansweredandyouhaveenclosedappropriateevidence

ofyourhouseholdincomeforthetaxyear2012-13• ifapplicable,youhavelistedanybenefitsreceivedinIncomeDetails,Benefits(PartC)andthesehavebeen

confirmedbyyourbenefitsoffice• youhaveenclosedallappropriateevidence,whererequired.Thismayinclude: -incomeevidenceforthe2012-13taxyeare.g.aTaxCreditAwardNotice(formTC602)orP60

-arentalagreementorlandlord’sletterifyouhavearrangedyourlodgings.

Pleasereturnthecompletedformto:

Freepost RSLX-CAZR-RHLYLEARNER SUPPORT SERVICEBIRMINGHAMB24 9FDYouwillnormallyreceiveareplywithinthreeweeks.Ifyoudonothearfromuswithin three weekscalluson0800 121 8989.

This application pack contains

• Anapplicationform-StudentDetails(PartA),IncomeDetails(PartB),IncomeDetails,Benefits(PartC)• GuidanceNotestohelpyoufillintheform• Pre-paidenvelope

• UsetheenclosedGuidanceNotestohelpyoufillinthisform• FillintheformusingBLACK INKandinBLOCK CAPITALS• Markboxesclearly,likethis:• Writeasclearlyasyoucan.Ifwecannotreadtheform,wewillsenditbacktoyou.

Filling in this form

IMPORTANT: Photocopied forms will not be accepted. All incomplete forms will be returned as these cannot be processed.

IMPORTANT: PaymentsYou should apply for RSS as soon as possible. You should send photocopies of your evidence and these must be clear and complete. Incomplete or incorrect evidence will delay processing of your application.Payments will only be backdated to the beginning of the term in which the application is received by the Learner Support Service. RSS payments cannot be made until we have received all the information we need.

Additional help

Ifyouneedhelp to complete this form,youcan:• calluson0800 121 8989between9.00amand5.00pmMondaytoFriday• Minicom:0800 917 6048 between9.00amand5.00pmMondaytoFriday• emailusatRSS@EFAlearnersupport.co.uk• visitourwebsiteatwww.gov.uk/residential-support-scheme

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Student Details (Part A)

Part A - to be filled in by the Student

Surname/FamilyName:

FirstName(s):

A1 - Your name

A3 - Your permanent home address (this must be in England)

HouseNo./FlatNo./Name:

Street/Road:

Town/City:

County:

Postcode:

A4 - Your contact details

EmailAddress:

HomePhoneNumber:

MobileNumber:

For office use only: Evidencereturned

Schemenumber

Recipient

D D M M 2 0 Y Y/

Howwouldyoulikeustocontactyou?

Email HomePhone MobilePhone Post

A2 - Your date of birth

D D M M Y Y Y Y Youmustbeaged16to18yearsold.Youmusthavestartedyourcoursebeforeyouturn19.

DateofBirth:

IMPORTANT: Backdating payments You should apply for RSS before your course starts where possible. To apply you must have an unconditional offer of a place. Applications may be made after the course has started but payments will only be backdated to the beginning of the term in which the application is received by the Learner Support Service.

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A5 - Equal opportunities monitoring (see page 5 of the Guidance Notes)

Doyouconsideryourselftohaveadisability?

Howwouldyoudescribeyourethnicorigin?

White

Mixed Asian or Asian British

Chinese or other ethnic groupBlack or Black British

Areyou: Male Female Prefernottosay

A6 - Your term time address, if known (see page 5 of the Guidance Notes)

If you have arranged where you will be lodging during your course, enter the address below. You must send us a rental agreement or landlord’s letter with your application form. This must show your name, your term time address, the dates of your tenancy, the cost of the rent and your landlord’s name, address and signature. Your landlord cannot be related to you.

If you have not yet arranged your lodgings leave questions A6 to A8 blank. You must send us a rental agreement or landlord’s letter once you have made arrangements. No RSS payments will be made until we have received this.

HouseNo./FlatNo./Name:

Street/Road:

Town/City:

County:

Postcode:

Isyourtermtimeaddress15milesorlessfromthecollegecampus?

Yes

No

Youmustenterthepostcode.

Go to A7

Ifyourtermtimeaddressismorethan15milesfromyourLearningProvideryouarenoteligibleforhelpfromtheResidentialSupportScheme.Calluson0800 121 8989.

Yes No Prefernottosay

British

Irish

Anyotherwhitebackground

African

Caribbean

Anyotherblackbackground

Chinese

AnyOther

WhiteandblackCaribbean

WhiteandblackAfrican

WhiteandAsian

Anyothermixedbackground

Indian

Pakistani

Bangladeshi

AnyotherAsianbackground

Prefernottosay

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A7 - Your landlord’s address or the agency to which you have to pay rent during your course (if known)

Landlord/AgencyName:

Address:

Postcode: Youmustenterthepostcode.

A9 - Your course

NameofLearningProvider:

CourseTitle:

Enteryourcoursetermdatesfor2013/14.AskyourLearningProvidertohelpyouifyoudonotknowthesedates.

Termstartdate:

Termenddate:

D D M M Y Y Y Y

D D M M Y Y Y Y

Autumn 2013

D D M M Y Y Y Y

D D M M Y Y Y Y

Spring 2014

D D M M Y Y Y Y

D D M M Y Y Y Y

Summer 2014

Whendoyouexpecttofinishthecourse?

Youshouldentertheactualcourseenddate(thiscouldbeadateinafutureacademicyear).

D D M M Y Y Y Y

Whendid/willyoustartthecourse? D D M M Y Y Y Y

A8 - Your rent (if known)

Entertheamountofrentyouwillbepayingperweek:or

£ £ £ £ . p p£

Doyouknowwhatdateyoudid/willtakeupyourtermtimeaccommodation?

D D M M Y Y Y Y

Entertheamountofrentyouwillbepayingpermonth:

£ £ £ £ . p p£

Yes Enterthedatehereand go to A9

No Wewillconfirmthisdatelater.Go to A9

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AccesstoHE BTECLevel3NationalCertificate/NationalDiploma

NVQLevel3 BTECLevel2FirstDiploma

NVQLevel2 BTECLevel1IntroductoryDiploma

NVQLevel1 Vocational-RelatedQualificationLevel3

InternationalBaccalaureate Vocational-RelatedQualificationLevel2

ALevel Howmany? GCSEatgradeA*toC Howmany?

ASLevel Howmany? GCSEatgradeDtoG Howmany?

Overseasqualifications.Ifyouhaveanoverseasqualification,youmustencloseaNationalRecognitionInformationCentre(NARIC)certificatewithyourapplication.YourLearningProvidermaybeabletohelpyouobtainone.IfyoudonotencloseaNARICcertificatewewillnotbeabletoprocessyourapplication.Seepage 5oftheGuidanceNotes.

Otherqualifications(forexampleOCR/CambridgeNationals/CityandGuilds).Enter the details in the box below. You must send a photocopy of your certificate(s) with your application.

Forthefollowingqualifications,tellusifyouhavethemandhowmanyyouhavefully completed.

A11 - Your qualifications (mark the boxes below)

Only tell us about qualifications that you have fully completed. Do not tell us about qualifications that you are due to start or are part way through. See pages 5-6 of the Guidance Notes.

A10 - Do you already have any qualifications?

Yes

No

Go to A11

Go to A12

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Student DeclarationIfyougivefalseorincompleteinformation,wemayhavetoreferthemattertothePolicetotakeappropriateaction.Aspartofourassessmentprocesswemaysampleapplicationformsandmayaskforfurtherevidence.Ifthatevidenceisnotprovided,orresultsinalowerawardbeingdue,wemaystopanyfuturepaymentsandseekrepaymentofanythingpaid.

I have read and understoodtheGuidanceNotessuppliedwiththisformincludingtheprivacynoticeaboveanddeclarethatallinformationandanyevidencegiveninsupportofthisapplicationiscorrectandcompletetothebestofmyknowledgeandbelief.

I understand that:• IneedconfirmationfromtheLearnerSupportServicethatmyapplicationhasbeenapprovedbeforeanyResidential

SupportScheme(RSS)paymentscanbemade

• ifIknowinglymakeafalsestatementorprovidefalseinformation,Imayrendermyselfliableforprosecution

• IamapplyingforRSSfundsasmymainsourceoffundingformyresidentialandassociatedcosts.IwilltelltheLearnerSupportServiceandmyLearningProviderifIreceivehelpwiththesecostsfromothersourcese.g.HousingBenefit

• IamauthorisingtheLearnerSupportServicetocontactandshareinformationwithmyLearningProviderasrequiredforthepurposesofconfirmingthedetailsofmyapplicationandattendancemonitoring

• ImustinformtheLearnerSupportServiceandmyLearningProviderimmediatelyifIwithdrawfromorstopattendingmycourseandthatImayhavetorepaypartoralloftheresidential/lodgingsandassociatedcostsifIwithdrawfrommycourse

• ImustrefundanysumsoverpaidtomeortomyLearningProviderifrequiredtodoso

• ImustdeclareanyfundingIreceiveunderRSSifIapplyforhelpfromothersources

• theinformationIhavegivenmaybesharedwithotherrelevantagenciesororganisationsforthepurposesofassessingmyeligibilityforfundingand/orthepreventionoffraud

• ImayonlyclaimRSSpaymentsifImeettheresidencyconditionsforthisscheme.

RSS payments cannot be made until A13 has been fully completed by an Authorised Officer at your Learning Provider.You must complete Income Details (Part B) and complete Income Details, Benefits (Part C), if applicable.

A12 - Privacy Notice and Student Declaration

Privacy Notice

ForthepurposesoftheDataProtectionAct1998,theDepartmentforEducation(DfE)isthedatacontrollerforanypersonaldatathatissuppliedonthisapplicationform.ThisinformationwillbeprocessedbytheLearnerSupportServiceonbehalfoftheEducationFundingAgency(EFA),anexecutiveagencyoftheDfEinordertoconsideryoureligibilitytoreceiveResidentialSupportScheme(RSS)funding.

Anypersonaldatareceivedwillbeheldconfidentiallyandonlysharedwithotherrelevantorganisationstoassessyoureligibilityforfundingand/orthepreventionoffraud.Anyothersharingofpersonaldatawillonlytakeplacewherethelawallows.

MarkboxAifyouDO NOTwishustotellAdult1namedinquestionB2ofIncomeDetails(PartB)aboutyourcompletedapplicationandpayments.

MarkboxBifyouDO NOTwishustotellAdult2namedinquestionB2ofIncomeDetails(PartB)aboutyourcompletedapplicationandpayments.

TheEFAvaluesyourviewsontheeducationortrainingyoureceiveandusesfeedbacktohelpbringaboutimprovementsforstudents.Studentsmaybecontactedbymailand/ortelephoneandaskedtotakepartinsurveyswhichwillenabletheEFAtomonitoritsperformance,improvethequalityofitsservicesandplanfutureprovision.

MarkboxCifyouDO NOTwishtobecontactedbytheEFAtotakepartinsurveysandresearch.

FurtherinformationabouttheEFAcanbefoundathttp://www.education.gov.uk/aboutdfe/executiveagencies/efa

A

B

C

IMPORTANT: You are not required to sign and date this application, however by submitting this form and applying for RSS you are agreeing to all the statements and conditions above. You are also consenting to the Learner Support Service contacting you in order to discuss your eligibility for funding or any of the information provided.

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A13 - Learning Provider Declaration - to be completed by an authorised officer

NameofLocalAuthorityOfficerconsulted:

NameofLocalAuthorityOffice: Officer’scontactnumber:

NameofAuthorisedOfficer:

JobTitle:

NameofLearningProvider:

Address:

Postcode:

ContactNumber:

EmailAddress:

IMPORTANT: You are not required to sign and date this application, however by completing this declaration you are confirming that the details are correct.

I declare that:

• theStudenthasafulltimeplaceontheabovecourse(thisisaplacethatisfundedasfulltimebytheEFA)andtheyhavesatisfiedtheresidency requirementsissuedbytheEFAforpaymentofResidentialSupportSchemefunding.TheStudentissettledintheUKandhasbeenresidentinEnglandforthethreeyearspriortothecoursestartdate.Seepage 8oftheGuidanceNotes

• wheretheStudentislivingincollegeaccommodation,therentisbeingchargedatthestandardrateapplicabletoallstudents• theStudent’shomeLocalAuthorityhasconfirmedthatthereisnotasimilaralternativecourseavailablewithindaily

travellingdistance.Iconsultedtheindividualwhosedetailsareshownbelow.

Yes NoIsthiscourse16-19funded?(Seepage 8oftheGuidanceNotes).

Before the Student’s application can be processed, the Learning Provider must confirm that they have consulted the Student’s home Local Authority to confirm that no similar course is available within daily travelling distance (allowing for time, cost and the nature of the journey). The following declaration must be completed in full by the Learning Provider.

Student’sFullName:

CourseTitle:

CourseLevel:

RSSwillsupporttheStudent’s first fullLevel2orfirst fullLevel3course(inexceptionalcircumstances,RSSmaysupportstudyforasecondLevel2orsecondLevel3qualification,oraLevel1qualification.Foradvicecalluson0845 600 7979.)

Other(pleasestate):

Level4Level1 Level2 Level3

Learning Provider contact details

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Income Details (Part B)

Part B - to be filled in by the adult(s) and the Student

IMPORTANT: We need the income details for your household for the tax year 6 April 2012 to 5 April 2013 to assess your application. We need the income for you and the adult(s) who are mainly responsible for you. Before you complete this section, make sure you read pages 9-18 of the Guidance Notes.

All students will be assessed on this basis unless there are exceptional circumstances that mean you should be assessed as an Independent Student. The exceptional circumstances that apply are that at the start of the academic year:

• you are, or you have been, married or in a civil partnership or living with someone as if you are married• you are a parent and are the main carer of the child(ren)• you have supported yourself for at least three consecutive years (36 months) before you started your course• you have no living parents• you are estranged from your parent(s) and you live independently from them. This will not apply if you are living away from

home because you are undertaking a course

If you think you should be assessed as an Independent Student, do not complete Income Details (Part B) or Income Details, Benefits (Part C). Call us on 0800 121 8989.

If your circumstances change and you meet one of the above conditions part way through the academic year call us on 0800 121 8989.

B2 - Your relationship to the Student

Surname/FamilyName:

FirstName:

RelationshiptoStudent:

Other(pleasestate):

Adult 1 Adult 2

Mother

Father

Aunt

Uncle

Grandparent

Step-parent

Partnerofparent

Mother

Father

Aunt

Uncle

Grandparent

Step-parent

Partnerofparent

B1 - Does the Student normally live with you at the address shown in question A3?

Yes Go to B2 Call us on 0800 121 8989No

Enterthedetailsbelowifyouaretheadult(s)responsiblefortheStudentandtheylivewithyou(whentheyarenotstudyingawayfromhome)attheaddressshowninquestionA3.

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Questions B3 to B11 are about Income Details - these must be for the 2012-13 tax year (6 April 2012 to 5 April 2013).

If you are the adult(s) mainly responsible for the Student go to question B3.If you are the Student go to question B5. You must tell us about any income you received in the 2012-13 tax year.

TheeasiestwaytotellusaboutyourincomeistosendyourlatestTaxCreditAwardNotice(formTC602)thatcorrectlystatesyourtotalhouseholdincomeforthetaxyear2012-13.You should send us a photocopy but this must be clear and complete.ATaxCreditAwardNoticeissenttoyouifyoureceiveWorkingTaxCreditorChildTaxCredit.Thefigureyouneedtogiveusisyourtotal incomeshownontheinsidepagesofyournotice,asshowninthepicture-nottheamountoftaxcreditsyoureceive.Do notsendusyourReviewNotice(formTC603R)oraTaxCreditAwardNoticethatdoesnotstateyourcorrectincomeforthetaxyear2012-13.IfyoudonothaveaTaxCreditAwardNoticethatcorrectlystatesyourincomeforthetaxyear2012-13,youcanapplyusingaP60,benefitsinformation,orotherevidence.Formorehelp,calluson0800 121 8989.

frontpage

insidepage

Tax credits award for 06/04/2007 to 05/04/2008

7

3Example

Example

Tax credits award for 06/04/2013 to 05/04/2014

Your income for the year 6 April 2012 to 5 April 2013

Date18May2013

Totalincomefortheyear6April2012to5April2013

0345 300 3900

0345 300 3909

B3 - Do you have a Tax Credit Award Notice (form TC602) that correctly states your household income for the tax year 2012-13?

Writeinyourtotalincome,asshownontheTaxCreditAwardNotice.Rounddowntothenearestpound.Donotshowpence.

Forexample:

YesNo

£

£

IMPORTANT: If the Student received any income in the tax year 2012-13, they must also complete questions B5 to B11, as appropriate, and send us the required evidence.

Go to B12.DonotfillinanymorequestionsinIncomeDetails(PartB).Do not fill in Income Details, Benefits (Part C). Youhavecompletedyourapplication.YoumustencloseaphotocopyofyourTaxCreditAwardNoticewithyourapplication.

Fill in the following questions if you received any income in the tax year 2012-13 and have not enclosed a Tax Credit Award Notice showing your income for the tax year 2012-13. If you received benefits for only part of the tax year 2012-13 you must also complete Income Details, Benefits (Part C).

B4 - Did you receive Income Support, Income-based Jobseeker's Allowance, Income-related Employment and Support Allowance or Pension Credit for the whole of the tax year 2012-13?

Go to B12. IncomeDetails,Benefits(PartC)mustbefilledinbyyouandtheofficethatdealswithyourbenefitpayments.WhenPartChasbeencompletedandreturnedtoyou,sendittouswiththerestoftheapplication.

YesNo

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BeforeyoucompletequestionsB5 to B7,seepages 13-15oftheGuidanceNotesforhelponwhatincomeyouneedtoincludeineachbox.Whereincomefromemploymenthasbeenreceived,entertheamountyoureceivedandsendustheevidencerequired.Round your answers down to the nearest pound and do not include pence.

B5 to B7 - Income from employment

Adult 1

B5 Writeinyourtotalearningsasanemployeefrom all jobs before taking off Tax and National Insurance contributions.

B6 Writeinthevalueofanybenefitsinkindfromyouremployer,e.g.companycarandfuelortaxablevouchers.

£

B7 Writeinyourtotalincomefromself employment. £

£

Adult 2

£

£

£

£

Student

£

£

YouneedtosendusanyP60orP60Uformsyouhavefor2012-13.

YouneedtosendusanyP9DorP11Dformsyouhavefromyouremployerfor2012-13.

YouneedtosendusyourSelfAssessmentTaxCalculationform(SA302)for2012-13,orcalluson0800 121 8989ifyoudonothaveone.

WorkoutthetotalforbothadultsandfortheStudentofanyotherincome,includingpensions,usingthetablebelow.Youmayberequiredtoprovidesupportingevidence.

B8 - Other income (see pages 16-17 of the Guidance Notes)

Annual amount of:

Forincomepaidinaforeigncurrency,statetheequivalentinBritishpounds.Seepage 17oftheGuidanceNotes.

If you were employed for only part of the tax year 2012-13 include this income in questions B5 to B7.If you received benefits for only part of the tax year 2012-13 you must complete Income Details, Benefits (Part C).If you received any ‘other’ kinds of income during the tax year 2012-13 you must complete question B11.

Total (ifthismakesaminusfigure,justenter£0)

AdultDependant'sGrantormiscellaneoustaxableincome(includethefullamount)

Total other income (rounddowntothenearestpound)

Nowaddtogetherthetotals

Nowdeduct£300

Incomefromsavingsandinvestments

Incomefromproperty

Trusts,settlementsandestates

Foreignincome

Pensions(state,occupationalorpersonal)

Notionalincome

Student

+

Adult 1 Adult 2

+ =

£

3 0 0-

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B11 - During the tax year 2012-13, did you receive any of the ‘other’ kinds of income listed on page 18 of the Guidance Notes?

B9 to B10 - Allowable deductions (see pages 17-18 of the Guidance Notes)

££B9 Writeinanypersonal pension contributionsyoupaidintoaregisteredscheme.Enterthegrossamount.

B10 Statutory Maternity, Ordinary or Additional Paternity or Adoption Pay.Beforeyouanswerthisquestion,seepage 18oftheGuidanceNotes.

££

Donotincludepensioncontributionspaidthroughyouremployer.TheywillalreadyhavedeductedyourpensioncontributionsfromthepayfigureenteredonyourP60orP45.

Adult 1 Adult 2

£

£

Student

IfYes,telluswherethisincomecamefromandwhenyoureceiveditintheboxbelow.Youdonotneedtotellushowmuchincomeyoureceived.SeetheGuidanceNotesforwhat‘other’incomemeansbeforeyouanswerthisquestion.IfNo, gotothedeclarationatquestionB12.

Privacy Notice

B12 - Privacy Notice and Declaration

Student and Adult Declaration

ForthepurposesoftheDataProtectionAct1998,theDepartmentforEducation(DfE)isthedatacontrollerforanypersonaldatathatissuppliedonthisapplicationform.ThisinformationwillbeprocessedbytheLearnerSupportServiceonbehalfoftheEducationFundingAgency(EFA),anexecutiveagencyoftheDfEinordertoconsideryoureligibilitytoreceiveResidentialSupportScheme(RSS)funding.

Anypersonaldatareceivedwillbeheldconfidentiallyandonlysharedwithotherrelevantorganisationstoassessyoureligibilityforfundingand/orthepreventionoffraud.Anyothersharingofpersonaldatawillonlytakeplacewherethelawallows.

FurtherinformationabouttheEFAcanbefoundathttp://www.education.gov.uk/aboutdfe/executiveagencies/efa

Ifyougivefalseorincompleteinformation,wemayhavetoreferthemattertothePolicetotakeappropriateaction.Aspartofourassessmentprocesswemaysampleapplicationformsandmayaskforfurtherevidence.Ifthatevidenceisnotprovided,orresultsinalowerawardbeingdue,wemaystopanyfuturepaymentsandseekrepaymentofanythingpaid.

I / We have read and understoodtheGuidanceNotessuppliedwiththisformincludingtheprivacynoticeaboveanddeclarethatallinformationandanyevidencegiveninsupportofthisapplicationiscorrectandcompletetothebestofmy/ourknowledgeandbelief.

I / We understand that:

• confirmationisneededfromtheLearnerSupportServicethatthisapplicationhasbeenapprovedbeforeanyResidentialSupportScheme(RSS)paymentscanbemade

• I/Weshareresponsibilityfortheinformationgivenwithanypartnernamedonthisform• iftheStudentapplyingforRSSwiththisformdoesnotkeeptotheRSSrules,oriftheyleavetheircourse,theywillnot

beeligibletoreceivefurtherpaymentsandanyRSSoverpaidmayneedtoberepaid• theinformationI/wehavegivenmaybesharedwithotherrelevantagenciesororganisationsforthepurposesof

assessingthisapplicationforfundingand/orthepreventionoffraud• theStudentiseligibleforRSSonresidencygroundsasexplainedonpage 8oftheGuidanceNotesandcanprovide

suitableevidenceasproofifrequired.

IMPORTANT: You are not required to sign and date this application, however by submitting this form and applying for RSS you are agreeing to all the statements and conditions in the declaration above. You are also consenting to the Learner Support Service contacting you in order to discuss your eligibility for funding or any of the information provided.