81955-COI-NHS App Form FULL-T

Request for a Current Year Income Assessment (Form CYIA)
Please complete this form if the total income for the current financial year is, or is expected to be, at least 15%
less than the previous financial year.
Please complete all sections in full, where applicable and send to:
DST-NWSSP-SAS, Cwmbran House, Mamhilad Park Estate, Pontypool, NP4 0XS
Student name
Reference number SAS
Sections 1-4 of this form should be completed by the parent(s) (if student is classed as dependent) or the spouse/
partner/civil partner of the student (if student is classed as independent).
Section 1
Title
Mr / Mrs / Miss / Ms / Other:
Surname
Forenames
Address
Postcode
Daytime phone number (
)
Mobile phone number
Occupation
What is your relationship to the student?
Section 2
Please indicate the reason for your change in income by ticking the appropriate box below
and provide a brief explanation if necessary. You must enclose supporting proof of your change of
income such as a P45 or a letter from your employer.
Change of employment
Redundancy
Long term sickness
Other
Retirement
Please give details below
Declaration of income
Section 3
If the student has been classed as ‘dependent’, then the ‘Person 1’ and ‘Person 2’ sections below should
be completed by the student’s parent(s).
If the student has been classed as ‘independent’, then the ‘Person 1’ section below should be completed
by the student’s spouse/partner/civil partner.
Please supply details of your estimated income and expenses in order for the current year income
assessment to be carried out. In ALL cases you must enclose documentary evidence to support any income
and expenses that you declare.
(a) Estimated income for the current financial year ending 5 April
(Enter year)
Person 1
£
Total gross taxable income from salary or wages
during the above year
Other income - such as benefits in
kind i e , car / fuel benefits, medical
insurance, etc
Please provide more details
Income from self-employment during the above year
Income from land, properties or furnished lettings
during the above year
Pension income received during the above year
Please provide more details
Gross Bank/Building Society interest (including
tax) during the above year
Sick pay paid by an insurance company and/or any other
taxable s t a t e benefits (such as Job Seekers Allowance
or contribution based Employment Support Allowance)
during the above year
Please provide more details
(including the name of any benefit
you have declared above)
Gross unearned income - such as dividends from shares or
company directorship during the above year
Please provide more details
Person 2
£
(b) Estimated expenses for the same period as above
Write NIL where there are no expenses
Person 1
Person 2
£
£
Employee pension payments
Personal pensions/retirement annuities
Other expenses on which HM Revenue and Customs
gives tax relief
If the student has been classed as an ‘independent’ student and is in receipt of Dependants Allowance,
Parent Learning Allowance and/or Childcare Allowance, then the following information should also be
provided by the student’s spouse/partner/civil partner:
Estimated expenses for the current financial year ending 5 April
(enter year)
Income Tax during the above year
National Insurance Contributions during the above year
Mortgage / rent payments during the above year
Life assurance premiums during the above year
Section 4 Declaration
I declare that I am the person named in Section 1 of this form.
I confirm that I will inform the Student Awards Services immediately if there is any change to
the details set out in Section 2 of this form, or if the figures set out in Section 3 are
subsequently revised by HM Revenue and Customs, and I understand and accept that any
changes will require this NHS bursary funding assessment to be reviewed.
I confirm that I will inform the Student Awards Services immediately in the event that there is
any change to my personal or contact details set out in Section 1.
I consent to the disclosure of information to and by any organisations detailed in Section 2 of
this form for the purpose of verification of information provided on this form.
I understand that the administration of NHS student bursaries and responsibility for counter
fraud and security management in the NHS are both responsibilities of the NHS Wales Shared
Services Partnership. I understand that Student Awards Services may share the information
on this form with the Cardiff and Vale University Health Board Counter Fraud Department for
the purposes of the prevention, detection, investigation and prosecution of fraud or any other
unlawful activity affecting the NHS.
I declare that I am the person named in Section 1 of this form and that the information given
on this form and in the supporting documents provided is complete and accurate. I
understand and accept that if I provide false or misleading information, financial support may
be refused or withdrawn and I may be liable to prosecution and/or civil proceedings.
Signature
Print name
Date
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