Student Reimbursement Voucher

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Please provide evidence of income plus copies of receipts (For Discretionary applications)

All reimbursements are made by online bill payment only.

STUDENT NAME: *

BUDGET: Sixth Form Bursary

DATE: *

YYYY

SIGNED BY BUDGET HOLDER:

DETAILS OF PURCHASE - For Discretionary Bursary) Please add items with costs below: *

To receive your bursary by bank transfer, please complete bank account details below: (IN BLOCK CAPITALS)

Account Name: *

Account Number: *

Sort Code: *

Bank Name *

· Please note that it is the responsibility of the claimant to ensure that the bank information provided is accurate

· Please be advised that any costs which may occur as a result of incorrect information will fall to the claimant

· Where bank details are not provided, cheque reimbursement will be made

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