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Student Finance Declaration

2016/17
Forename(s)
Maryam Sign AND date this form in ink
Surname and return all printed pages to:
Student Finance England

Bakhtiari PO Box 306
Darlington
Customer Reference Number DL1 9NU
5 7 0 9 4 8 2 5 0 5 9

You must sign, date and return this form before any payment will be made to you.
By signing this declaration form you are signing up to receive student finance as well as accepting
and agreeing to the associated terms and conditions. This declaration is not linked
to specific loan or grant amounts so even if the amount of student finance you are entitled
to changes, you still need to sign and return it or you wont be paid anything.

Before signing and returning your completed form, you Loan Contract
should read the data protection statement online at a I confirm I have read and understood the terms and
www.gov.uk/studentfinance conditions guide available online at
This declaration covers all of the student finance www.gov.uk/studentfinance
available to students for academic year 2016/17. b I acknowledge and agree that any loan(s) made
to me by the Secretary of State for Education, the
You should read the specific terms and conditions
lender (which includes any persons exercising
about loans, Childcare Grant and Disabled Students
functions on behalf of the Secretary of State
Allowances because they will affect you if you apply
pursuant to section 23(4) of the Teaching and Higher
for them at any time in academic year 2016/17. If you
Education Act 1998 as amended from time to time or
dont apply for these in academic year 2016/17 their
successor legislation, the Act) will be on the terms
specific terms and conditions will not affect you.
set out in these declarations and in Regulations
Your application for financial support may be which are made under section 22 of the Act as
delayed unless you sign and date this declaration. amended from time to time.
General Declaration c I acknowledge and agree that in the event that
I have: (i) reached the age of 18 years; and (ii)
I confirm that to the best of my knowledge and belief,
have entered into one or more agreements for a
the information I have provided is true and complete.
loan under section 22 of the Teaching and Higher
If it is not, I understand that I may not receive
Education Act 1998 (and relative secondary
financial support, any support I have had may be
legislation) before I reached the age of 18 years,
withdrawn and I could be prosecuted.
upon signing this declaration I am agreeing to
I agree to give the Student Loans Company ratify any and all such student loans. I understand
(SLC) any information they require to process my that ratification of any agreement for a loan made
application and agree to tell them immediately if my with me before I reached the age of 18 years is a
circumstances change in any way that might affect statutory precondition of my eligibility for student
my entitlement to financial support. I understand support after attaining the age of 18 years.
that if I do not do this I may not receive any further
d I undertake to repay the lender any loan(s) made to
payments, and may have to repay the financial
me, together with all and any interest, penalties and
support I have received.
charges which apply.
I agree that in the event of receiving an overpayment
e I agree that any loan(s) made to me as a
of financial support, I am obligated to repay this in
consequence of the acceptance of my application
full.
by the lender is a/are contract(s) between me and
I understand that if I have provided details of my the lender which binds me from the payment to me
UK Passport, SLC will verify those details with Her of the first loan advance and that the repayment of
Majestys Passport Office. any such loan(s), together with all and any interest,
penalties and charges which apply, will be due by
me to the lender as a debt.

SFE/OND/1617
f I agree that I shall be obliged to make repayment of m If I breach any of the terms under which any loan(s) will
my loan(s), together with all and any interest, penalties be made I agree that I will be obliged to pay any charges
and charges which apply, to such address as shall be and penalties which may apply under the Teaching
notified to me in writing and that any services in respect and Higher Education Act 1998 and the regulations
of my loan(s) may be provided at such address or made under that Act, as amended from time to time or
other address(es) as the lender may from time to time successor legislation and/or regulations.
determine and that the service of providing the loan is n I understand that the Student Loans Company (SLC)
provided at the lenders principal address. will check my National Insurance number and personal
g I agree that any action for repayment and/or in respect details with the Department for Work and Pensions
of or in connection with my loan(s) and/or all and any (DWP). If I do not know my National Insurance number,
interest, penalties and charges which apply, will be or if the number I provide cannot be authenticated, DWP
brought before the ordinary civil courts and shall be will trace and give my number to the lender.
governed by the general rules of civil procedure. o If I have broken the terms of this contract I agree that
h I agree that my request for a loan, the loan and the the lender may share information held about me and my
contract between me and the lender shall be governed account with any person, including the government or a
by the law of the place of my home address as stated in government agency of another country, who may assist
my application (or, if my address is outside the United in establishing my whereabouts and/or in taking action to
Kingdom, English law). recover outstanding loan amounts.
i I irrevocably agree that the courts of the part of the Disabled Students Allowances (DSAs)
United Kingdom in which my home address stated in I understand that any equipment I receive through DSAs
my application is situated (or the English, Scottish and must be used for my course of study and SLC is not
Northern Ireland courts where my address is outside the responsible for paying any repair costs.
United Kingdom) shall have non-exclusive jurisdiction
to hear any action or proceedings arising out of or in I understand Student Finance England will pay the
connection with the loan and the contract between suppliers of any equipment and support directly.
me and the lender and I irrevocably submit to the Childcare Grant
jurisdiction of those courts and waive any objection to I understand that if I do not take up my childcare, or if I
the jurisdiction of those courts, provided that this shall change to a childcare provider who is not registered or
not limit the lenders rights to take proceedings against approved, I will have to pay back any overpayment.
me in any other court of competent jurisdiction. I understand that if I do not provide evidence of
j I agree that from the date I submit this form until the childcare costs within the timescales set, I might lose
date when my loan(s), together with all and any interest, my entitlement. Also if my payments to my childcare
penalties and charges which apply, is fully repaid I will provider are different from the estimates I provide,
notify the lender of any changes in the personal details I understand that further payments will increase or
(including National Insurance number) and contact decrease accordingly, or if no further Childcare Grant
details I have provided as required in accordance with payments are due to be paid to me, I may be liable to
the regulations referred to in paragraph b. repay any difference.
k In the event that I leave the United Kingdom to reside I confirm that neither I nor my husband, wife, civil partner
outside the United Kingdom or that for any other reason or cohabiting partner have chosen to receive support
I am outside the UK tax system, I undertake to inform for childcare from the childcare element of the Working
the lender in accordance with the regulations referred Tax Credit or Universal Credit and I agree to tell SLC
to in paragraph b and I undertake to provide the lender immediately if I or my husband, wife, civil partner or
with my new and any subsequent contact details until cohabiting partner does receive this support.
my loan, together with all and any interest, penalties and
charges which apply, is fully repaid.
l I agree to take all future action requested by the lender
and provide the lender with all information required to
ensure repayment, in accordance with the regulations
referred to in paragraph b.

Customer Reference Number DfE


5 7 0 9 4 8 2 5 0 5 9

Your signature Todays date


DAY MONTH YEAR
X / /

Sign AND date this form in ink and return all printed pages to the address shown on the first page.

SFE/OND/1617