Personal Information:

Contact

Course Information:

Residency:

Bank Details:

Other Funding:

All Students who are eligible to apply for funding from other sources must do so in the first instance.
Your Hardship Fund application will not be accepted until you have applied and have had a final
decision made on your application from the external funding body.

• All Higher Education students must apply to Student Finance NI

• All Further Education Full Time students 19+ must apply for a Further Education Award

• All Further Education Full Time students under 19 must apply to EMA and Travel Pass

• Part Time Further Education students on an eligible course must apply for a PT FE Award

Are you receiving or expect to receive financial assistance from any of the following sources?

Financial Need:

(You must complete this section to indicate what assistance you potentially need)

Please tick the categories you wish to be assessed for assistance with:

Notes

• Exam and other related fee costs are not covered

• Full Time Students Only

• If you live more than 3 miles away from campus (Receipts required)

• Receipts required (essential items)

• Assistance towards costs

Financial Details:

Please answer the following questions, evidence may be required to support your answers:

If you answered No to all questions, please supply you parental Income below
If you answered Yes to at least one question, please supply your own and partners Income below

*Household Income Details:

*Previous Education:

Non or partial completion of this section will result in a void application

Student Consent:

We need you to consent to communicate with any appropriate private and governmental agencies in
order to obtain and release information (both verbally and in written format) to enable a complete
and fair assessment of your application. All information shared will be handled in a confidential
manner.

I understand that I may revoke my consent at any time and this revocation must be delivered in
written format to The Liberation Foundation admin team. This consent form will be valid from the
date it is signed until I have completed or withdrawn from my course.

Student Statement

You can use this section to explain any/all of the following: reason for non-academic progression of
course level, financial difficulties or income and expenditure. Please provide documentary evidence
where possible to support your statement.

*Student Declaration

(you must read and sign this section)

I certify that all particulars given by me on this form are correct and that all relevant information has
been included. I understand the information provided will be handled in accordance with the
General Data Protection Regulation. I understand that it is my responsibility to supply all the relevant
documents to support my application, as well as any additional information that the panel requires in
a timely manner. I understand that the onus is on me to prove my need for financial assistance.
If I receive Hardship funds from The Liberation Foundation I undertake to:

• Advise the Liberation Foundation immediately if I withdraw or cease to attend the course and
  I will pay back the amount awarded to me.

• Refund any over payment, which may have occurred for whatever reason by the Liberation
  Foundation. I also understand that if my attendance level drops below 80% my award will be
  withdrawn.

Tutor Verification:

(to be completed by Tutor/Co-ordinator only)

I (Tutor Name) certify that the applicant is registered as a:

FULL TIMEPART TIME

Student is studying an accredited qualification and from the start of their course has maintained an overall
attendance of at least 80%.