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8/6/2019 Ema Wales Standard Application Form
http://slidepdf.com/reader/full/ema-wales-standard-application-form 1/24
SFW/EMA/F/V1011
Education Maintenance Allowance
Application Form for
EMA in 2010/11
student finance wales
www.studentfinancewales.co.uk/EMA
E M A
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EMA
1Completethe form
2Return the
form
3Receive your award letter
Use this form to apply for EMA for 2010/11 if you intend to study at a school or college in
Wales from September 2010. If you are not sure if you will continue studying, or where you
will study, you can still apply.
You need to:
• Complete Sections A to H of the form.• Make sure your parent(s)/guardian(s) or partner complete Sections I and J if they need
to. This will depend on your answers in Section E.
• Send original evidence to support your application. Any evidence needed is indicated
by this icon and details about the evidence can be found in the guidance notes.
• Sign the Student Declaration on page 7.
Don’t forget:
• To tell us your bank details in Section F. We can’t pay you if we don’t know them.
• Read the guidance notes if you need any help with the questions on the form.
• Call us on 0845 602 8845 or visit our website at www.studentfinancewales.co.uk/EMA
if you need any further help.
You need to:
• Send your completed form to us with all the evidence we need by June 2010 to make
sure your EMA entitlement is agreed and in place well in advance of your first 2010/11
term.
• Make sure all the evidence we need is sent with the form. You can send your completed
form to us even if you are still waiting for evidence. Once you have the remaining
evidence you can send it to us separately at a later date.
• Pay the correct postage. We recommend you also get proof of postage in case there
are any delivery problems.
Don’t forget:
• To get the envelope weighed before you return it so that you pay the correct postage.
If you don’t your EMA payments may be delayed.
• To get payments backdated you need to return the form within 8 weeks of starting your
course.
You will receive a letter when we receive your application form. If you do not receive a
letter within two weeks of sending your form, please contact us.
We will:
• Send you an award letter telling you how much your weekly EMA entitlement is for
academic year 2010/11.
Don’t forget:
• To keep your award letter because your school or college may ask to see it when you
sign your Learning Agreement with them for academic year 2010/11.
• You need to sign a Learning Agreement before you will receive any EMA payments.
Send your form back to us as soon as possible to make sure your payments are made on
time. If you don’t, there may be a delay to your payments. The latest date you can return your
form and any information and evidence we have asked for is 31 August 2011. If you miss this finaldeadline you will not get any EMA payments for academic year 2010/11.
We will only send you an award letter when your application is fully complete.
This means we must have all of the information and evidence required. If we need
any further information or evidence to complete our assessment, we will contact you.
We can only work out your EMA entitlement if you complete all relevant parts of the
application form, send the evidence we need and sign the Student Declaration on page 7.
It’s time to apply for EMA for academic year 2010/11
Applying is as easy as 1, 2, 3!
!
!
!
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SECTION A – YOUR PERSONAL DETAILS
If you are an existing EMA student, please provide yourCustomer Reference Number:
Q1. Title Mr Mrs Miss Other
First name(s)
Surname/Family name
Sex Male Female
Date of birth
In which town or city were you born?
Q2. Home address
Postcode
Home telephone number
Mobile telephone number
Email address
Security Details
Q3a. Please provide a ‘Secret Answer’.It is important you make your Secret Answer easy to remember as we will ask you toconfirm this whenever you call us.
Q3b. Please provide a ‘hint’ question to remind you of your Secret Answer.
For example, if you chose ‘Superman’ as your Secret Answer then your ‘hint’ question couldbe ‘What is the name of my favourite superhero?’
If you ever forget your Secret Answer we will ask you this ‘hint’ question to help youremember it.
YEARMONTHDAY
INTERNAL REFERENCE NUMBER: (For internal use only)
SECTION B – YOUR SCHOOL OR COLLEGE DETAILS
Please enter the details of the school or college where you intend to study from 1 September 2010.If you are unsure where you will be studying from September 2010, please enter the details of theschool or college you are currently attending.
Q1. Name of school or college
Campus
Q2. School or college address
Postcode
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SECTION C – YOUR NATIONALITY AND RESIDENCY DETAILS
Q1. Which best describes you? Tick one box from a to h.
Once you have ticked a box follow the arrows, answer any relevant questions and read theinstructions on what to do next.
a. I am a UK national
OR
I have ‘Settled Status’ or'Indefinite Leave to Enter orRemain' in the UK
b. I am an EUnational
c. I have, or my familymember* has, beengranted ‘Leave toenter or remain’ in theUK
I have been ordinarilyresident in:
• the UK
for 3 years prior to thefirst day of my course
Yes No
I have been ordinarily resident in:
• the UK
• the EU/EEA
• Switzerland
for 3 years prior to the first day ofmy course
Yes No
* your family member means your husband, wife, civil partner, parent or step-parent.
go to section E go to section D go to section E
YEARMONTHDAY
From
YEARMONTHDAY
To
First address:
Why were you there:
SECTION D – YOUR RESIDENCY HISTORY
Q1. Details of your residence for the three years before the start of the first academic year ofyour course.
You are NOTeligible forEMA
Tick Tick Tick
I have been ordinarilyresident in:
• the UK
for 3 years prior to thefirst day of my course
Yes No
go to section E
Go to section Cof the notes
go to section E
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SECTION C – YOUR NATIONALITY AND RESIDENCY DETAILS
d. I am a childof a Swissnational
e. I am, or my familymember* is, an EEAor Swiss nationalwho is working/ hasworked or is lookingfor work in the UK
f. I am a child of aTurkish nationalwho isworking/hasworked in the UK
g. I have, or myfamily member*has, refugeestatus in the UKOR I have EUtemporaryprotection statusin the UK
h. Noneofthese
I have been ordinarily resident in:
• the UK
• the EU/EEA
• Switzerland
for 3 years prior to the first day ofmy course
I have been ordinarily resident in:• the UK
• the EU/EEA
• Turkey
• Switzerland
for 3 years prior to the first day ofmy course
You are NOTeligible forEMA
You are NOTeligible forEMA
You are NOTeligible forEMA
Yes No Yes No
go to section E go to section E go to section E
SECTION D – YOUR RESIDENCY HISTORY
YEARMONTHDAY
From
YEARMONTHDAY
To
Second address:
Why were you there:
Tick Tick Tick Tick Tick
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SECTION F – YOUR BANK OR BUILDING SOCIETY ACCOUNT DETAILS
• You must provide us with details of an account that accepts direct credits.
• Enter the full name of the account holder, as it is written on your bank or building society
statement or card.
• You can find your sort code and account number on your bank or building society statements.• Your building society roll number can contain up to 18 letters and numbers, for example,
JOHNSO12345678. Some building societies ask you to complete this field to let them make
automatic payments into your account. If you are not sure of your roll number ask your building
society for advice.
• If you do not complete this section correctly, your EMA award may be delayed.
If you have any exceptional circumstances which prevent you from opening a bank or
building society account in your own name please tick here.
Name of account holder
Name of bank or building society
Sort code
Account number
Building society roll number(if applicable)
- -
SECTION E –YOUR INDEPENDENCE DETAILS
This section helps to decide whether you are a dependent or an independent student, and
therefore, whose income needs to be taken into account when assessing your entitlement to
financial support.
If you answer ‘Yes’ to ANY of the questions below you may be considered independent.
If you answer ‘No’ to ALL of the questions below you are considered dependent.
Q1. Are you estranged from your parent(s)/guardian(s)?
Q2. Are you living under Local Authority care?
(for example, with foster parents)
Q3. Do you receive Income Support or Income Based
Employment and Support Allowance in your own name?
Q4. Are you responsible for a child of your own?
Q5. Are you currently a Young Person in custody/detention
within the Youth Justice System?
if ‘Yes’ go to Q3
Yes No
Yes No
Yes No
Yes No
Yes No
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f i n a n c e w a l e s SECTION I – YOUR HOUSEHOLD’S FINANCIAL DETAILS
This section should be completed by:• the student’s parent(s)/guardian(s) if the student is dependent.
• the student and their wife, husband, civil partner or partner (if applicable) if the student is:- estranged from their parent(s)/guardian(s) and- NOT living under Local Authority care and- NOT in receipt of Income Support or Income Based Employment and Support Allowance.
You must answer every question, entering the amount of income received. If you did notearn/receive any of the income types, you must enter £0.00 on the application form.It is essential that you provide accurate and complete income details. If you do not, it may preventthe student from receiving their full EMA entitlement.
Q1. Relationship to applicant
First name
Surname/Family name
Benefit Income
Q2. If either Person 1 or Person 2 is in receipt of Income Support
or Income Based Employment and Support Allowance tick here:
Q3. Has your household been issued with a Tax Credit Award
Notification for tax year 2009-10 other than version 'R'? Yes No
If 'Yes', enter your total annual household income as it
appears on your Tax Credit Award Notification:
Employment Income
Q4. Please provide information for tax year 2009-10:
Salaries and wages
Self-employment income
Taxable Social Security Benefits
Other income
Q5. What is your total annual income?
Person 1 Person 2
£
£ £
£ £
£ £
£ £
£ £
£ £
£ £
Person 1 Person 2
if 'Yes', enter an
amount and go toSection J
if ticked, go straight
to Section J
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Person 1 Person 2
Private pension contributions
Additional Voluntary
Contributions (AVCs)
Wages for domestic helpbecause of incapacity
Any other expensesconnected with employment
TOTAL DEDUCTIONS
TOTAL INCOME
(This is your Q5 TOTAL minus Q6
TOTAL DEDUCTIONS)
Q6.
Q7.
£
£
£
£
£
£
£
£
£
£
£
£
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Deductions
SECTION I – YOUR HOUSEHOLD’S FINANCIAL DETAILS
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f i n a n c e w a l e s SECTION J – DECLARATION FOR PERSON(S) NAMED IN SECTION I
Please read the following declaration. We will not be able to process this application for
EMA unless you sign and date this declaration.
Before signing and returning the completed form, you should read the Data Protection Act within
the EMA guidance notes that accompany this form. This statement sets out who will use the
information provided on this application form and what they will use it for.
• I confirm that the information I have given on this form is correct and complete to the best of my
knowledge and belief.
• I understand that any attempt to dishonestly obtain EMA shall be treated as fraud and may result in
criminal and/or civil proceedings against me.
Person 1
Your full name (in BLOCK CAPITALS):
Your signature:
Date:
YEARMONTHDAY
Person 2
Your full name (in BLOCK CAPITALS):
Your signature:
Date:
YEARMONTHDAY
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EQUAL OPPORTUNITIES MONITORING
VOLUNTARY QUESTIONNAIRE
The following questions are voluntary - you do not have to answer them. Whether you answer them or
not will not affect your application for an EMA. If you do answer, the information may be used to help
the Welsh Assembly Government develop its policies in the future.
Q1. Do you consider yourself to have a disability? Yes No
Q2. What do you consider your nationality identity to be?(Choose as many or as few as apply).
Welsh
Irish
English
British
Scottish
Other
Q3. Choose ONE section from A to E, then tick the appropriate box to indicate your ethnic group.
A White D Black or Black British
British Caribbean
Any other white background African
Any other black background
B Mixed E Chinese or other ethnic group
White and Black Caribbean Chinese
White and Black African Any other
White and Asian
Any other mixed background
C Asian or Asian British
Indian
Pakistani
Bangladeshi
Any other Asian background
PLEASE RETURN THIS COMPLETED QUESTIONNAIRE WITH YOUR APPLICATION FORM
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Use the checklist below to make sure you have correctlycompleted this form before your send it to us!
Have you:
• Completed all the questions relevant to you in Sections A to H?
• Attached all the original documentary evidence we need with this form?
• Told us your bank details on page 6?
• Signed and dated the Student Declaration on page 7?
• Indicated whether you consent to us providing details of the progress of yourapplication and award to your parent(s)/guardian(s) or partner on page 7?
Checklist for Parent(s)/Guardian(s) or Partner (Person 1 & 2):So that we can assess this application have you:
• Completed and checked Sections I and J?
• Provided the correct total household income on page 9?
• Attached your household’s Tax Credit Award Notification (if applicable)?
• Attached evidence to support the statement of household income, if youare not in receipt of a Tax Credit Award Notification?
• Signed and dated the Declaration(s) on page 10?
Returning the formIt is recommended that you send the completed form to us with the evidence we need by June 2010to make sure your EMA entitlement is agreed and in place well in advance of your first 2010/11 term.
• To get backdated payments you need to return the form within 8 weeks of starting your course.
Any missing information or documentation may result in late payment of your EMA award.However, please do not delay sending in your application form if you are having difficultyproviding this evidence.
At the very latest, application forms, information and evidence must be received by 31 August 2011or you will not get any EMA payments for academic year 2010/11.
Postage• Check you have paid the correct postage before you post your EMA application. The
application form and envelope should be weighed and the correct postage paid or this will delaywhen we receive your application. This could mean a delay to the start of your payments.
• We recommend that you get proof of postage when returning this form in case of any
delivery problems. This is because any delay in receiving your application form could delay thestart of your payments.
Now send us your formOnce you have completed the checklist above, send your completed form and original supportingevidence, using the envelope provided, to:
EMA Wales Customer Services
Admail 3888
Cardiff
CF11 0ZY
If you have not received a letter from us within two weeks of sending your application form, oryou have any other queries, please contact us on 0845 602 8845.
If you have hearing difficulties, and wish to speak to an advisor using a minicom device, pleasecontact us on 0845 603 1693.
!
Tick
Tick
Tick
Tick
Tick
Tick
Tick
Tick
Tick
Tick
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Lwfans Cynhaliaeth Addysg
Ffurflen Gais am
LCA yn 2010/11
cyllid myfyrwyr cymru
www.cyllidmyfyrwyrcymru.co.uk/LCA
L C A
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ADRAN A – EICH MANYLION PERSONOLOs ydych yn fyfyriwr sy’n cael LCA yn barod,nodwch eich Cyfeirnod Cwsmer:
C1. Teitl Mr Mrs Miss Arall
Enw(au) cyntaf
Cyfenw/Enw teuluol
Rhyw Gwryw Benyw
Dyddiad geni
Ym mha dref neu ddinas y cawsoch eich geni?
C2. Cyfeiriad cartref
Côd post
Rhif ffôn cartref
Rhif ffôn symudol
Cyfeiriad e-bost
Manylion DiogelwchC3a. A fyddech gystal â nodi ‘Ateb Cyfrinachol’.
Mae’n bwysig bod eich Ateb Cyfrinachol yn un hawdd i’w gofio oherwydd byddwn yngofyn i chi gadarnhau hwn bob tro y byddwch yn ein ffonio.
C3b. A fyddech gystal â nodi cwestiwn ‘awgrymiadol’ er mwyn eich atgoffa o’ch Ateb Cyfrinachol.
Er enghraifft, os byddwch yn dewis ‘Superman’ fel eich Ateb Cyfrinachol, gallech nodi ‘Bethyw enw fy hoff arwr i?’ fel eich cwestiwn ‘awgrymiadol’.
Os byddwch yn anghofio eich Ateb Cyfrinachol, byddwn yn gofyn y cwestiwn‘awgrymiadol’ hwn i chi er mwyn eich helpu i’w gofio.
BLWYDDYNMISDYDD
CYFEIRNOD MEWNOL: (At ddefnydd mewnol yn unig)
ADRAN B – MANYLION EICH YSGOL NEU GOLEGDylech nodi manylion yr ysgol neu’r coleg lle’r ydych yn bwriadu astudio o 1 Medi 2010.Os nad ydych yn siŵr ble y byddwch yn astudio o fis Medi 2010, dylech nodi manylion yr ysgol neu’r coleg yr ydych yn ei mynychu/fynychu ar hyn o bryd.
C1. Enw’r ysgol neu’r coleg
Campws
C2. Cyfeiriad yr ysgol neu'r coleg
Côd post
SFW/EMA/F/V1011
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y f y r w y r c y m r u ADRAN C – EICH MANYLION CENEDLIGRWYDD A PHRESWYLIO
C1. Pa un sy'n eich disgrifio chi orau? Ticiwch un blwch o a i h.
Ar ôl i chi roi tic mewn blwch, dilynwch y saethau, atebwch unrhyw gwestiynau perthnasol adarllenwch y cyfarwyddiadau am yr hyn i'w wneud nesaf.
a. Rydw i'n wladolyn y DU
NEU
Rydw i wedi sicrhau ‘StatwsPreswylydd Sefydlog’ neurhoddwyd 'Caniatâd Mynediadneu Aros am amser Amhenodol'i mi yn y DU
b. Rydw i'nwladolynyr UE
c. Rydw i, neu aelod o'mteulu*, wedi sicrhau'Caniatâd mynediadneu aros' yn y DU
Rydw i wedi bod ynpreswylio fel arfer yn:
• y DU
am 3 blynedd cyndiwrnod cyntaf fy nghwrs
Rydw i wedi bod yn preswylio felarfer yn:
• y DU• yr UE/AEE• y Swistir
am 3 blynedd cyn diwrnod cyntaf fy nghwrs
* mae aelod o'ch teulu yn golygu eich gŵr, eich gwraig, eich partner sifil, eich rhiant neu'ch llys-riant.
ewch i adran E ewch i adran D ewch i adran E
BLWYDDYNMISDYDD
Rhwng
BLWYDDYNMISDYDD
A
Cyfeiriad cyntaf:
Pam oeddech chi yno:
ADRAN D – HANES EICH MANYLION PRESWYLIO
C1. Eich manylion preswylio yn ystod y tair blynedd cyn dechrau blwyddyn academaidd gyntaf eich cwrs.
NID ydychyn gymwys igael LCA
TiciwchTiciwchTiciwch
Ydw ydwNac
Ydw ydwNac
Rydw i wedi bod ynpreswylio fel arfer yn:
• y DU
am 3 blynedd cyndiwrnod cyntaf fy nghwrs
ewch i adran E ewch i adran E
Ydw ydwNac
Ewch i Adran Cy nodiadau
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ADRAN C – EICH MANYLION CENEDLIGRWYDD A PHRESWYLIO
d. Rydw i'nblentyngwladolyny Swistir
e. Rydw i, neu aelodo'm teulu*, ynwladolyn yr AEEneu'r Swistir sy’ngweithio/wedi bodyn gweithio neusy’n chwilio amwaith yn y DU
f. Rydw i'n blentyngwladolynTwrci sy'ngweithio/wedibod yn gweithioyn y DU
g.Rydw i, neu aelodo'm teulu*, wedisicrhau statwsffoadur yn y DUNEU rydw i wedisicrhau statwsamddiffyn drosdro yr UEyn y DU
h. Dim uno'r rhain
Rydw i wedi bod yn preswylio fel arfer yn:
• y DU• yr UE/AEE• y Swistir
am 3 blynedd cyn diwrnod cyntaf fynghwrs
Rydw i wedi bod yn preswylio fel arfer yn:
• y DU• yr UE/AEE• Twrci• y Swistir
am 3 blynedd cyn diwrnod cyntaf fynghwrs
NID ydychyn gymwys igael LCA
NID ydychyn gymwys igael LCA
NID ydychyn gymwys igael LCAewch i adran E ewch i adran E ewch i adran E
ADRAN D – HANES EICH MANYLION PRESWYLIO
BLWYDDYNMISDYDD
Rhwng
BLWYDDYNMISDYDD
A
Ail gyfeiriad:
Pam oeddech chi yno:
Ticiwch Ticiwch Ticiwch Ticiwch Ticiwch
Ydw ydwNac
Ydw ydwNac
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ADRAN F – MANYLION EICH CYFRIF BANC NEU GYMDEITHAS ADEILADU
• Rhaid i chi ddarparu manylion cyfrif sy’n fodlon derbyn credydau uniongyrchol.
• Nodwch enw llawn deiliad y cyfrif, yn unol â’r hyn a nodir ar eich datganiad neu’ch cerdyn banc
neu gymdeithas adeiladu.• Gallwch weld eich côd didoli a rhif eich cyfrif ar eich datganiadau banc neu gymdeithas adeiladu.
• Gall eich rhif rhôl cymdeithas adeiladu gynnwys hyd at 18 o lythrennau a rhifau, er enghraifft,JOHNSO12345678. Bydd rhai cymdeithasau adeiladu yn gofyn i chi nodi’r rhif hwn er mwyncaniatáu iddynt wneud taliadau awtomatig i’ch cyfrif. Os nad ydych yn gwybod eich rhif rhôl,gofynnwch i’ch cymdeithas adeiladu am gyngor.
• Os na fyddwch yn llenwi’r adran hon yn gywir, efallai y bydd eich dyfarniad LCA yn cael ei oedi.
Os ydych yn wynebu unrhyw amgylchiadau arbennig sy’n eich atal rhag agor cyfrif banc neu
gymdeithas adeiladu yn eich enw chi, ticiwch yma.
Enw deiliad y cyfrif
Enw’r banc neu’r gymdeithas adeiladu
Côd didoli
Rhif y cyfrif
Rhif rhôl cymdeithas adeiladu
(os yw’n berthnasol)
- -
ADRAN E – MANYLION AM EICH ANNIBYNIAETH
Mae’r adran hon yn helpu i benderfynu a ydych yn fyfyriwr dibynnol neu annibynnol, ac felly,incwm pwy y bydd angen ei ystyried wrth asesu’ch hawl i gael cymorth ariannol.
Os byddwch yn ateb ‘Ydw’ i UNRHYW UN o’r cwestiynau isod, efallai y byddwch yn cael eichystyried yn annibynnol.
Os byddwch yn ateb ‘Nac ydw’ i’r HOLL gwestiynau isod, fe’ch ystyrir yn ddibynnol.
C1. A ydych wedi ymbellhau o’chrhiant(rhieni)/gwarcheidwad(gwarcheidwaid)?
C2. A ydych yn byw dan ofal Awdurdod Lleol?(er enghraifft, gyda rhieni maeth)
C3. A ydych yn cael Cymhorthdal Incwm neu Lwfans Cyflogaetha Chymorth wedi’i Seilio ar Incwm yn eich enw chi?
C4. A ydych yn gyfrifol am eich plentyn eich hun?C5. A ydych yn Berson Ifanc yn y ddalfa/yng nghadw'r
System Cyfiawnder Ieuenctid ar hyn o bryd?
os ‘Ydw’ewch i C3
Ydw ydwNac
Ydw ydwNac
Ydw ydwNac
Ydw ydw
Nac
Ydw ydwNac
8/6/2019 Ema Wales Standard Application Form
http://slidepdf.com/reader/full/ema-wales-standard-application-form 19/24
7SFW/EMA/F/V1011
c yl l i d m yf yr w
yr c ymr u
Os ydych yn fyfyriwr dibynnol,dylech roi’r ffurflen gais hon
i’ch rhiant(rhieni)/gwarcheidwad(gwarcheidwaid)er mwyn iddynt lenwi Adrannau I a J.
Myfyriwr Dibynnol
Ar gyfer yr holl fyfyrwyr annibynnol eraill, rydych
wedi gorffen llenwi'r ffurflenyn barod. Ewch i dudalen 11.
Os ydych wedi ateb ‘Ydw’yn C1 a ‘Nac ydw’ yn C3
yn Adran E, rhaid i chia’ch partner (pan fohynny’n berthnasol),lenwi Adrannau I a J.
Myfyriwr AnnibynnolMyfyriwr Annibynnol
ADRAN G – CANIATÂD I RANNU
Bydd y wybodaeth y byddwch yn ei ddarparu yn y ffurflen hon yn cael ei ddarparu i LywodraethCynulliad Cymru, y Cwmni Benthyciadau Myfyrwyr (SLC) neu unrhyw sefydliadau eraill a ddefnyddir gan Lywodraeth Cynulliad Cymru at ddibenion gweinyddu'ch cais am LCA. Gallai'r cyrff hynddefnyddio'r wybodaeth hon at ddibenion cynnal ymchwil y farchnad.
Os nad ydych yn rhoi eich caniatâd i’ch gwybodaeth gael ei ddefnyddio er mwyn cynnal ymchwil yfarchnad, ticiwch yma.
Gwybodaeth bwysig os ydych yn byw gyda’ch rhiant(rhieni)/gwarcheidwad(gwarcheidwaid)neu bartner:
Mae’n bwysig ein bod yn gwybod a fyddwch yn gadael i ni drafod eich cais a’ch dyfarniad gyda’chrhiant(rhieni)/gwarcheidwad(gwarcheidwaid) neu’ch partner. Ni allwn roi gwybodaeth am eich caisneu’ch dyfarniad i unrhyw un heb i chi gytuno.
• Rydw i’n rhoi fy nghaniatâd i Dîm Gwasanaethau Cwsmeriaid LCA Cymrui ddarparu manylion am gynnydd fy nghais a’m dyfarniad i’r unigolyn aenwyd fel Unigolyn 1 yn Adran l y ffurflen gais hon.
a, phan fo hynny’n briodol
• Rydw i’n rhoi fy nghaniatâd i Dîm Gwasanaethau Cwsmeriaid LCA Cymrui ddarparu manylion am gynnydd fy nghais a’m dyfarniad i’r unigolyn aenwyd fel Unigolyn 2 yn Adran l y ffurflen gais hon.
ADRAN H – DATGANIAD Y MYFYRIWR
A fyddech gystal â darllen y datganiad canlynol. Ni fyddwn yn gallu prosesu’ch cais am LCAoni bai eich bod yn llofnodi ac yn dyddio’r datganiad hwn.
Cyn llofnodi a dychwelyd y ffurflen ar ôl ei llenwi, dylech ddarllen y Datganiad Diogelu Data yn nodiadaucanllaw LCA a anfonwyd gyda’r ffurflen hon. Mae’r datganiad hwn yn nodi pwy fydd yn defnyddio’r wybodaeth a nodir yn y ffurflen gais hon a’r hyn y byddant yn defnyddio’r wybodaeth ar ei gyfer.
• Rydw i’n cadarnhau, hyd eithaf fy ngwybodaeth a’m cred, bod y wybodaeth a nodais yn y ffurflenhon yn gywir ac yn gyflawn.
• Rydw i’n cadarnhau fy mod wedi cyflwyno dogfennaeth ategol yn unol â’r nodiadau canllaw.
• Deallaf y bydd unrhyw ymgais i geisio sicrhau LCA mewn ffordd anonest yn cael ei thrin fel twyll acfe allai arwain at ddwyn achos troseddol a/neu sifil yn fy erbyn.
Enw llawn y myfyriwr (mewn PRIFLYTHRENNAU):
BLWYDDYNMISDYDDLlofnod y myfyriwr: Dyddiad:
Adrannau y bydd angen i chi eu llenwi nawr:
Ydw ydwNac
Ydw ydwNac
8/6/2019 Ema Wales Standard Application Form
http://slidepdf.com/reader/full/ema-wales-standard-application-form 20/24
ADRAN I – MANYLION ARI ANNOL EICH CARTREF
Dylai’r canlynol lenwi’r adran hon:• rhiant(rhieni)/gwarcheidwad(gwarcheidwaid) y myfyriwr os yw’r myfyriwr yn ddibynnol.
• y myfyriwr a'i wraig, gŵr, partner sifil neu bartner (pan fo hynny’n berthnasol) os yw’r myfyriwr:- wedi ymbellhau o’u rhiant(rhieni)/gwarcheidwad(gwarcheidwaid) a- HEB fod yn byw dan ofal Awdurdod Lleol a- HEB fod yn cael Cymhorthdal Incwm neu Lwfans Cyflogaeth a Chymorth wedi’i Seilio ar Incwm.
Rhaid i chi ateb pob cwestiwn gan nodi cyfanswm yr incwm a gafwyd. Os na wnaethoch chiennill/derbyn unrhyw rai o’r mathau o incwm, rhaid i chi nodi £0.00 ar y ffurflen gais.Mae’n hanfodol eich bod yn darparu manylion cywir a chyflawn am eich incwm. Os na f yddwch yngwneud hynny, gallai hyn atal y myf yriwr rhag cael swm llawn LCA y mae ganddynt yr hawl i’w gael.
C1. Perthynas gyda’r ymgeisydd
Enw cyntaf
Cyfenw/Enw teuluol
Incwm gan Fudd-daliadau
C2. Os yw Unigolyn 1 neu Unigolyn 2 yn cael Cymhorthdal Incwm neu
Lwfans Cyflogaeth a Chymorth wedi’i Seilio ar Incwm, ticiwch yma:
C3. A yw’ch cartref wedi cael Hysbysiad Dyfarniad Credyd Treth
ar gyfer blwyddyn dreth 2009-10 ac eithrio fersiwn 'R'? Ydy ydy
Os 'Ydy', nodwch gyfanswm incwm blynyddol eich cartref fel y
mae’n ymddangos ar eich Hysbysiad Dyfarniad Credyd Treth:
Incwm gan Gyflogaeth
C4. A fyddech gystal â darparu gwybodaeth ar gyfer blwyddyn dreth 2009-10:
Cyflogau
Incwm hunangyflogedigBudd-daliadau Nawdd
Cymdeithasol Trethadwy
Incwm arall
C5. Beth yw cyfanswm eichincwm blynyddol?
8 SFW/EMA/F/V1011
c y l l i d m
y f y r w y r c y m r u
Unigolyn 1 Unigolyn 2
£
£ £
£ £
£ £
£ £
£ £
£ £
£ £
Unigolyn 1 Unigolyn 2
os 'Ydy', nodwchswm ac ewch i Adran J
os ticiwyd, ewchyn syth i Adran J
Nac
8/6/2019 Ema Wales Standard Application Form
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9SFW/EMA/F/V1011
Unigolyn 1 Unigolyn 2
Cyfraniadau i bensiwn preifat
Cyfraniadau GwirfoddolYchwanegol (AVCs)
Cyflog am help domestigoherwydd analluogrwydd
Unrhyw dreuliau eraill sy’ngysylltiedig â chyflogaeth
CYFANSWM Y DIDYNIADAU
CYFANSWM YR INCWM(Hwn yw'ch CYFANSWM C5yn llai CYFANSWM YDIDYNIADAU yn C6)
C6.
C7.
£
£
£
£
£
£
£
£
£
£
£
£
c yl l i d m yf yr w
yr c ymr u
Didyniadau
ADRAN I – MANYLION ARIANNOL EICH CARTREF
8/6/2019 Ema Wales Standard Application Form
http://slidepdf.com/reader/full/ema-wales-standard-application-form 22/24
ADRAN J – DATGANIAD AR GYFER UNIGOLYN(UNIGOLION) A ENWIR YN ADRAN I
A fyddech gystal â darllen y datganiad canlynol. Ni fyddwn yn gallu prosesu’ch cais amLCA oni bai eich bod yn llofnodi ac yn dyddio’r datganiad hwn.
Cyn llofnodi a dychwelyd y ffurflen ar ôl ei llenwi, dylech ddarllen y Datganiad Diogelu Data yn ynodiadau canllaw LCA a anfonwyd gyda’r ffurflen hon. Mae’r datganiad hwn yn nodi pwy fydd yn
defnyddio’r wybodaeth a nodir yn y ffurflen gais hon a’r hyn y byddant yn defnyddio’r wybodaethar ei gyfer.
• Rydw i’n cadarnhau, hyd eithaf fy ngwybodaeth a’m cred, bod y wybodaeth a nodais yn y ffurflenhon yn gywir ac yn gyflawn.
• Deallaf y bydd unrhyw ymgais i sicrhau LCA mewn ffordd anonest yn cael ei thrin fel twyll ac feallai arwain at ddwyn achos troseddol a/neu sifil yn fy erbyn.
10 SFW/EMA/F/V1011
c y l l i d m
y f y r w y r c y m r u
Unigolyn 1
Eich enw llawn (mewn PRIFLYTHRENNAU):
Eich llofnod:
Dyddiad:
BLWYDDYNMISDYDD
Unigolyn 2
Eich enw llawn (mewn PRIFLYTHRENNAU):
Eich llofnod:
Dyddiad:
BLWYDDYNMISDYDD
8/6/2019 Ema Wales Standard Application Form
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11SFW/EMA/F/V1011
c yl l i d m yf yr w
yr c ymr u
HOLIADUR GWIRFODDOL MONITRO
CYFLE CYFARTAL
Mae’r cwestiynau canlynol yn gwestiynau gwirfoddol – nid oes yn rhaid i chi eu hateb. Ni fydd eichpenderfyniad i’w hateb neu beidio eu hateb yn effeithio ar eich cais am LCA. Os byddwch yn euhateb, efallai y defnyddir y wybodaeth i helpu Llywodraeth Cynulliad Cymru i ddatblygu ei pholisïauyn y dyfodol.
C1. A ydych yn ystyried bod gennych anabledd? Ydw Nac ydw
C2. Beth ydych chi’n ystyried yw eich cenedligrwydd?(Dewiswch gymaint neu gyn lleied ag sy’n berthnasol.)
Cymreig
Gwyddelig
Seisnig
Prydeinig
Albanaidd
Arall
C3. Dewiswch UN adran o A i E, yna ticiwch y blwch priodol i nodi’ch grŵp ethnig.
A Gwyn D Du neu Ddu Prydeinig
Prydeinig Caribïaidd
Unrhyw gefndir gwyn arall Affricanaidd
Unrhyw gefndir du arall
B Cymysg E Tsieineaidd neu grŵp ethnig arall
Gwyn a Du Caribïaidd Tsieineaidd
Gwyn a Du Affricanaidd Unrhyw gefndir arall
Gwyn ac Asiaidd
Unrhyw gefndir cymysg arall
C Asiaidd neu Asiaidd Prydeinig
Indiaidd
Pacistanaidd
Bangladeshaidd
Unrhyw gefndir Asiaidd arall
A FYDDECH GYSTAL Â DYCHWELYD YR HOLIADUR HWN, WEDI’I LENWI, GYDA’CH FFURFLEN GAIS
8/6/2019 Ema Wales Standard Application Form
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