Student Awards Agency for Scotland

Gyleview House, 3 Redheughs Rigg, Edinburgh, EH12 9HH Telephone: 0300 555 0505 Fax: 0131 244 5887 websi e: www.saas.gov.uk

Application for a student loan for living costs in session 2011-2012

Your SAAS reference number (please fill in black ink): 1. Your personal details
Title Date of birth D !irst name"s# D M M Surname National Insurance Number

student's ref no

$ountry of birth

District or sub-district where your birth certificate was issued

our ban% or building society sort code ! 2. oan amount !

our ban% or building society account number

I want to a&&ly for the student loan I am entitled to for academic year '())-'()'* The amount I want to a&&ly for is+ The highest amount a,ailable to me "&lease tic% if a&&ro&riate# The amount of "write in the amount# !. oan contacts ou must gi,e us the names and addresses of "#$ contacts. one of whom should normally be a relati,e. &artner. ne/t of %in or guardian* The contacts must %$" li,e at the same address* &irst contact (relative' guardian) Name+ 0000000000000000000* 1elationshi& to you+ 0000000000000** Address+ 000000000000000000** 00000000000000000000000 000000000002ostcode+ 0000000 Second contact Name+0000000000000000000 Address+ 00000000000000000** 0000000000000000000000 0000000000000000000000 0000000000*2ostcode+ 0000000 A3)4oan or

5ome &hone number "including area code# 00000000000* 0

5ome &hone number "including area code# 00000000000**

A3)4oan

(. )ankruptc* and se+uestration Are you ban%ru&t. or ha,e you e,er been declared ban%ru&t. or has your estate e,er been tem&orarily ta%en form you6 ,. "erm-time address 7e only need to %now your term-time address if it is different from your home address+ 000000000000000000000000000000000000000000000 0000000000000000000000**2ostcode+ 00000000000000000** Do you want the Student 4oans $om&any to send corres&ondence to this address rather than your home address6 -. Your age at t.e start of *our course ou only need to answer this 8uestion if you were aged 9( to 9: at the start of your course* After com&leting your course. do you &lan to wor%6 /. Student oan declaration (*ou must sign t.is) This loan is made under the ;ducation "Scotland# Act )<=(. its regulations and any amendments to them* As far as I %now . the information I ha,e gi,en on this form is com&lete and accurate* I will tell SAAS and the Student 4oans $om&any 4imited "S4$# immediately if my circumstances change in any way that might affect this a&&lication for su&&ort* I agree to re&ay any amounts that are lent to me. together with interest and any &enalties and charges that a&&ly. in line with the rele,ant legislation as amended from time to time* In the e,ent that I lea,e the >nited ?ingdom. I will tell SAAS and S4$ and &ro,ide them with my new and any subse8uent contact details until my loan. together with interest and any &enalties and charges that a&&ly. is fully re&aid* I agree that the law under which the loan"s#are made to me by S4$ shall be go,erned by the law that a&&lies to the &lace of my address as stated in this form "or the ;nglish. Scottish and Northern Irish courts where my address is outside the >nited ?ingdom* I will submit to the @urisdiction of those courts. &ro,ided that this shall not limit SAAS and S4$As rights to ta%e &roceedings against me in another court of com&etent @urisdiction* I gi,e &ermission for SAAS and S4$ to confirm my National Insurance number and rele,ant information with the De&artment for 7or% and 2ensions "D72#* If I do not %now my National Insurance number. or if the D72 cannot confirm the number I gi,e you. I gi,e the D72 &ermission to trace my number and gi,e it to SAAS and S4$* I gi,e &ermission for SAAS and S4$ to share information with each other about my loan award from SAAS* es No es No es No

Signature: 0000000000000000000000000** 0ate+ 000000000*0 #arning: 1f *ou make a false statement or declaration to get a loan' *our application 2ill not be valid and *ou ma* be prosecuted.

A3)4oan