Current Year Income Assessment Form - Academic Year 2016/17 Page 5
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2
3
4
5section
D
income deductions
Person 1
Person 2
Q1
Do you expect to pay any private pension contributions?
Yes
No
Yes
No
Total expected private pension contributions
£
£
Q2
Do you expect to pay any Additional Voluntary Contributions
(AVCs)?
Yes
No
Yes
No
£
£
Total expected AVCs
Q3
Do you expect to have any allowable expenses on which you
Yes
No
Yes
No
will claim tax relief?
£
£
Total expected allowable expenses on which you will claim tax
relief
Declaration
Make sure you sign the declaration in ink. Digital signatures won’t be accepted.
Our Data Protection Statement sets out who will use the information provided on this form and what they will
use it for. Before signing this form please read our statement online at:
If you cannot sign the form it must be signed on your behalf by your Power of Attorney. The Power of
Attorney letter must be sent with the application before a signature from that Power of Attorney will be
accepted.
This application for financial support may be delayed unless you sign and date this declaration.
• I confirm that to the best of my knowledge and belief, the information I have provided is true and
complete. If it is not, I understand the student may not receive financial support, any support they have
had may be withdrawn and I could be prosecuted.
• I agree to provide any further information in relation to the applicant’s application for financial support
as may reasonably be required, and I agree to provide immediate notice of, and details in relation to,
any change in circumstances that might in any way affect this application for financial support.
Person 1
Person 2
Your full name (in BLOCK CAPITALS)
Your full name (in BLOCK CAPITALS)
Your signature
Your signature
r
r
DAY
MONTH
YEAR
DAY
MONTH
YEAR
/
/
/
/
Date
Date
SFW/CYI/1617
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