Application

Grant for Disabled &

Disadvantaged Students
___
Grants may be available to students studying civil engineering on an ICE accredited
course at a UK University. Applicants must be student members of ICE with a minimum
membership of one-year duration.

Please read the Guidance Notes before completing this form. If you have any queries
or are unsure how to answer any of the questions please call 01444 417 979, during
normal office hours for assistance.

Step 1: Your details

Surname
Forename(s)
Term Time Address
Postcode
Tel No Mobile No
Email
Home Address (if different)
Postcode
Tel No
Date of Birth
ICE Membership No
Which address would you like to use for correspondence: Term Home
At your term time address, do you live: alone / with spouse or partner / with parents /
in halls / in shared house
If in a shared house, how many people do you share with:
Is this your first degree course? Yes / No

Step 2

Why you are applying for assistance from the Benevolent Fund? Continue on an extra
sheet if necessary.

A charitable company limited by guarantee, registered in England and Wales, Company number 6708655, Charity Number 1126595
Step 3: Course and Dependent’s Details
Course Name
Campus
How long is your course? years
Which year of study are you in? 1 / 2 / 3 / 4
Are you repeating a year? Yes / No
Are you on a placement year? Yes / No
If yes, is it: paid / unpaid
Please indicate how your tuition fee is being paid
Tuition Fees grant/loans (pa) £
Local Education Authority (LEA) contribution (pa) £
Parental contribution (pa) £
Your own contribution (pa) £
Name of LEA*
*Please enclose a copy of your LEA support notice
Please give details of anyone who is financially dependent on you
Full Name Date of Birth
Have you applied to the Access to Learning Fund this academic year? Yes / No

Step 4: Monthly Income

Income (£) per month
Maintenance Grant (please specify)
Student loan
Parents’ Learning Allowance
Lone Parents Grant
Adult Dependents’ Grant
Childcare Grant
Disabled Students’ Allowance (DLA)
Net Earnings
Parental/Partner Contribution
Child Tax Credit
Working Tax Credit
Child Benefit
Housing Benefit
Council Tax Support
Income Support
Jobseekers’ Allowance
Universal Credit
Scholarship/trusts/grants
Disability Benefits (specify)
Other Income including Savings (specify)
Partner’s Income
Net Earnings
Other
Overall Total

A charitable company limited by guarantee, registered in England and Wales, Company number 6708655, Charity Number 1126595
Step 5: Expenses

Outgoings (£) per month

Council Tax
Tuition Fees
Rent/Mortgage
Living Expenses
Childcare Costs
Travel costs (during term-time)
Books/Stationery/Equipment etc.
Disability Costs not covered by DSA (specify)
Other exceptional costs (specify)

Overall Total

Step 6: Debts

Please include all your debts even if you are not behind with the payments. Continue on
an extra sheet, if necessary.

Priority Debts: mortgage and rent arrears, council tax, water, gas and electricity bills,
magistrates court fines, benefit overpayments, the Social Fund, hire purchase.

Non-priority debts: credit/store card debts, bank loans/overdrafts, catalogues, personal

debts to family/friends

Outstanding Annual
Creditor Balance Repayment

A charitable company limited by guarantee, registered in England and Wales, Company number 6708655, Charity Number 1126595
Step 7: Bank Accounts and Savings

Please list balances and overdraft facilities for all your bank and building society
accounts, including savings accounts. NB. You must provide 3 months statements for
all accounts and explain all credits into accounts.

Bank/Building Society
Account type
Balance £ Overdraft facility £
Bank/Building Society
Account type
Balance £ Overdraft facility £
Bank/Building Society
Account type
Balance £ Overdraft facility £
Step 8: Disability / Special Medical Needs

Do you have a disability or chronic medical condition? Yes / No

If yes, please provide details
Have you applied for a Disabled Students’ Allowance? Yes / No
Do you wish to apply for any financial assistance towards any special equipment/
material not covered by DSA? Yes / No
If yes, please provide details. Continue on a separate sheet, if necessary

Step 9: University supporting statement

Please ask your Head of Department to add their comments and recommendations for
assistance.
All applications must be signed by your Head of Department or his/her nominee

Signed Name
Tel No University Title
E-mail

A charitable company limited by guarantee, registered in England and Wales, Company number 6708655, Charity Number 1126595
Step 10: Declaration

I confirm that all the questions on this form have been fully and truthfully answered to the
best of my ability and that all income and assets have been declared. Where I have
provided details of my partner I confirm that I have done so with their consent.

In accordance with the Data Protection Act 1998, I hereby explicitly consent as follows:

• to permit the ICE Benevolent Fund staff to process the data provided in this form
and in all other communications from me to the Benevolent Fund in connection
with my application.

• to permit the disclosure of all data in this form to other associated charities who
may be able to provide assistance, for the purpose of processing.

I will inform the Benevolent Fund immediately if there are any changes in my
circumstances.

Signed Name Date

Please return this form to the address below and remember to include all the relevant
supporting documents. A checklist of documents is given in the guidance notes. Copied
or scanned documents are acceptable, and we would advise against sending original
documents. If original documents are sent, they will be returned to you as soon as
possible.

ICE Benevolent Fund

5 Mill Hill Close
Haywards Heath
West Sussex RH16 1NY

A charitable company limited by guarantee, registered in England and Wales, Company number 6708655, Charity Number 1126595