aansoek om finansiële steun/application for financial ... - Matie

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AANSOEK OM FINANSIËLE STEUN/APPLICATION FOR FINANCIAL ASSISTANCE
LENINGS/ LOANS - NSFAS & US
KONTROLELYS / CHECK LIST
2013
Voltooi in SWART ink / Complete this form in BLACK ink
Toekennings word bepaal deur finansiële behoefte en daarom moet alle bydrae tot die gesinsinkomste verklaar word /
Awards are determined by financial need and therefore all contributions to the family income must be declared
Die Universiteit behou die reg voor om ALLE INLIGTING TE KONTROLEER en hierdie aansoek te kanselleer indien valse
inligting verstrek word / The University reserves the right to VALIDATE ALL INFORMATION and cancel this application if
false information is supplied
Pos aansoeke na Die Registrateur, Voorgraadse Beurse en Lenings, Privaat Sak X1, MATIELAND, 7602 / Forward application
to The Registrar, Undergraduate Bursaries and Loans, Private Bag X1, MATIELAND, 7602
Sluitingsdatum:
Closing date:
STUDENT:
30 Junie vir Voornemende Eerstejaars en 31 Julie vir Senior Studente
30 June for Prospective First Year Students and 31 July for Senior Students
________________________________________________
STUDENTENOMMER:
STUDENT NUMBER:
Merk die
gepaste
blokkie met
√.
Tick the
appropriate
block with
√.
DOKUMENTASIE / DOCUMENTATION
‣ Voltooi hierdie kontrolelys sorgvuldig om te
verseker dat die relevante dokumente aanheg is.
‣ Complete this check list with care to ensure that
you have attached all the relevant documents.
1 Jongste salarisstrokie- ouer/voog/eie/gade (nie ouer as
3 maande nie ). / Latest salary advice-parent /
guardian/own/ spouse (not older than 3 months)
2 Gewaarmerkte afskrif van die aansoeker se Suid-
Afrikaanse ID dokument. / Certified copy of the
applicant’s South African ID document.
3 Bewys van pensioen (‘n strokie/ bankstaat nie ouer as 3
maande)./ Proof of pension (a slip/bank statement not
older than 3 months)
6 Beëdigde verklaring tov werkloosheid van volwasse
gesinslede afhanklik van ouer inkomste. / Sworn
affidavit with regard to unemployment of adult
family member dependant on parent income.
7 Gewaarmerkte afskrifte van die famlielede se Suid-
Afrikaanse ID dokumente/ geboortesertifikate.
Certified copy of the family member’s South African ID
documents/ birth certificates.
19 Beëdigde verklaring tov werkloosheid of huisvrou
status van die moeder./ Sworn affidavit pertaining to
unemployment or housewife status of the mother.
21 Beëdigde verklaring tov onderhoud (geskeide - of
enkel ouers).
Sworn affidavit pertaining to maintenance ((divorced or
single parents).
22 Beëdigde verklaring tov informele inkomste (bv.spaza
kafee,loswerk,ens.) / Sworn affidavit in respect of
informal income (eg.spaza shop, odd jobs,etc.)
Merk die
gepaste
blokkie
met√ .
Tick the
appropriate
block with
√.
DOKUMENTASIE /DOCUMENTATION
‣ Voltooi hierdie kontrolelys sorgvuldig om te verseker dat
die relevante dokumente aanheg is.
‣ Complete this check list with care to ensure that you have
attached all the relevant documents.
22 Beëdigde verklaring tov inkomste verkry uit tydelik/deeltydse
werk. / Sworn affidavit pertaining to income derived from
temporary/part time work.
23 Waar beide ouers werkloos is, ‘n beëdigde verklaring tov
oorlewingsinkomste (bystand) van familie./
Where both parents are unemployed, a sworn affidavit with
regard to survival income (assistance) from family.
24 By voogdyskap, ‘n gesertifiseerde afskrif van doodsertifikaat
van ouer(s). / In case of guardianship, a certified copy of death
certificate of parent(s)
25 In geval van egskeiding, ‘n afskrif van die egskeidingsbevel. /
In case of divorce, a copy of the divorce settlement.
26 By boerdery, eie onderneming of BK, die geouditeerde
finansiële state. / In case of farming, own business or CC, the
audited financial statements.
28 Afskrif van die laaste belastingaanslag (IB 34) as bewys van
inkomste.
Copy of the last tax assessment (IT 34) as proof of income
29 Brief van die bank met betrekking tot die aansoek om
studielening indien u gesamentlike bruto inkomste meer as
R20 000 pm is. / Letter from the bank with regard to the
application for a study loan where gross income exceeds
R20 000 pm.
30 Bewys van registrasie van ‘n familielid wat ook tersiêr
studeer moet voor 30 Maart 2012 ingehandig word. / Proof of
registration of a family member’s tertiary studies must be
handed in before 30 March 2012.
Slegs vir
kantoorgebruik:
For office use
only:
% Krediete geslaag
% Credits passed
%
%% %
5%%
Middele Toets Bedrag
Means Test Amount
Eerste aansoek
First application
R
%% %
5%%
Voortsetting aansoek/
Continuing application

AFDELING A:
PERSOONLIKE INLIGTING VAN APPLIKANT
(Omkring asseblief wat op u van toepassing is.)
TITEL: me, mnr, ens.
TITLE: ms, mr, etc.
VOLLE NAAM
FULL NAME
ID NOMMER
ID NUMBER
KONTAKNOMMERS
CONTACT NUMBERS
VAN
SURNAME
SECTION A:
PERSONAL INFORMATION OF APPLICANT
(Please encircle what is applicable to you.)
PROGRAM /JAAR ( bv. BA I)
PROGRAMME /YEAR (eg. BA I)
SA BURGER Ja Nee
SA CITIZEN Yes No
Tuis/Home: Kode/Code Selnr / Cellno: Student Selnr/Cellno: Ouer/Parent
VERBLYF (studie by US)
RESIDENCE (studying at SU)
Ouers
Parents 1
Eie woning
Own Home 2
Privaat
Private 3
Universiteit met etes
University with meals 4
Universiteit sonder etes
University self catering 5
ADRES TYDENS STUDIE
ADDRESS WHILE STUDYING
WOONADRES (OUERS)
HOME ADDRESS (PARENTS)
PROVINSIE/PROVINCE
AFDELING B: GESINSINKOMSTE
• Vul asseblief u huidige maandelikse salaris- of toelaag (of ander
inkomste) in onder die bruto inkomste kolom.
• Heg asseblief die jongste salaris- of pensioenstrokie, WVF,
beëdigde verklaring, of rente op beleggings aan as bewys van u
inkomste.
• In die geval van boere en besighede, bv. ‘n eenmansaak of BK heg
die jongste geouditeerde state en belastingaanslag (IB 34) aan.
• Indien werkloos heg asb ‘n beëdigde verklaring van u
oorlewingsinkomste aan, bv onderhoud, familieskenkings, ander
donasies, ens.
INLIGTING
DETAIL
VADER
FATHER
MOEDER
MOTHER
VOOG
GUARDIAN
APPLIKANT
APPLICANT
GADE
SPOUSE
VOORLETTERS
INITIALS
VAN
SURNAME
VASTE EIENDOM: Huis, plaas, ens.
FIXED PROPERTY: House, farm, etc.
HUWELIKSTATUS VAN BROODWINNER Ongetroud Getroud
MARITAL STATUS OF PROVIDER
Unmarried 1 Married 2
GESINSLEDE AFHANKLIK VAN INKOMSTE (bv.Volwassene 2, Tersiêr 1, ens.)
FAMILY MEMBERS DEPENDANT ON INCOME (eg. Adults 2, Tertiary 1, etc.)
SECTION B: FAMILY INCOME
• Please indicate your current monthly salary or grant (or other
income) below the gross income column.
• Please attach the latest salary or pension slip, UIF, sworn
affidavit or interest on investments, as proof of your income.
• In case of farmers and businesses (CC or one-man business),
attach latest audited statement / tax assessment (IT 34).
• If unemployed, please attach a sworn affidavit to declare your
survival income e.g. maintenance, family supplements, other
donations, etc.
Markwaarde
Market Value
Wewenaar/Weduwee
Widower/ Widow 3
Volwassenes
Adults
BEROEP
OCCUPATION
R
Geskei
Divorced 4
Vervreemd
Seperated 5
Tersiêr
Tertiary
Verband uitstaande
Bond Outstanding
BRUTO INKOMSTE PM
GROSS INCOME PM
Lewensmaat
Life Partner 6
Skool
School
R
Weer getroud
Remarried 7
Voorskool
Preschool
AFDELING C: BEURSE EN /OF LENINGS WAARVOOR AANSOEK GEDOEN WORD. (Lys dit in die onderstaande tabel.)
SECTION C: BURSARIES AND/OR LOANS BEING APPLIED FOR. (List them in the table below.)
Versoek en voltooi asb ‘n aanhangsel indien u aansoek doen om: /Please request and complete an appendix if applying for:
virDippenaar Familietrust/Family Trust, Knacke, Du Toit Hugenote, Aristea, Familie Beurse / Family Bursaries en /and Eersterivier lening/loan.

AFDELING D: BYKOMENDE INLIGTING
SECTION D: ADDITIONAL INFORMATION
D I: DIE APPLIKANT MOET DIE ONDERSTAANDE VOLTOOI EN DIE NODIGE DOKUMENTE AANHEG
THE APPLICANT MUST COMPLETE THE FOLLOWING AND ATTACH THE NECESSARY DOCUMENTS
Indien u enige finansiële steun van ‘n borg, bank, maatskappy of trust ontvang, dui asseblief
R
die instansie aan sowel as die bedrag toegestaan.
If you are receiving any financial assistance from a sponsor, bank, company or trust, please
name the company as well as the amount awarded.
Het u van tevore ‘n NSFAS lening ontvang? Indien ja, vul asseblief die bedrag in.
Have you previously received a NSFAS loan? If so, please fill in the amount.
Ja
Yes
Nee
No
Was u finansieel selfversorgend vir 3 of meer jaar? (Heg asseblief bewys aan.)
Ja Nee
Have you been financially self supporting for 3 or more years? (Please attach proof.)
Yes No
Watter bedrag benodig u vir privaatlosies?
Which amount is needed for private residence?
D II: DIE OUER/VOOG/GADE MOET DIE ONDERSTAANDE VOLTOOI:
THE PARENT/GUARDIAN/SPOUSE MUST COMPLETE THE FOLLOWING:
Verskaf asseblief die inligting van ander gesinslede wat tans aan hierdie of ‘n ander tersiêre instansie studeer.
Hierdie inligting sal slegs in berekening gebring word indien die nodige bewys van registrasie ontvang is teen 30 Maart 2013.
Please provide the information of other family members currently studying at this or another tertiary institution.
This information will only be considered if proof of registration has been received by 30 March 2013.
Naam
Name
Studentenommer
Student number
Jaar
Year
Vanaf
From
Tersiêre Inrigting
Tertiary Institution
Tot
To
R
D III: INLIGTING VAN ONMIDDELLIKE FAMILIELEDE AFHANKLIK VAN TOTALE MAANDELIKSE INKOMSTE
INFORMATION OF IMMEDIATE FAMILY MEMBERS DEPENDENT ON THE TOTAL MONTHLY INCOME
• Hierdie afdeling moet voltooi word deur ‘n ouer, of ‘n wettige voog of huweliksmaat.
• Indien die applikant vir 3 jaar of langer finansieel selfonderhoudend was, of as beide ouers oorlede is en hy/sy nie ‘n wettige voog het nie,
moet die applikant self hierdie afdeling voltooi.
• Indien die persoon inkomste ontvang van meer as een bron, moet hierdie bronne gelys word.
• Indien die inkomste van lone of salarisse is, moet ‘n afskrif van die nuutste strokie saam met die aansoekvorm aangeheg word.
• Indien die inkomste van ‘n besigheidsopbrengs is, heg ‘n afskrif van u finansiële state vir belastingopgawe jaar aan.
• Indien die inkomste van onderhoud vir ‘n kind is waar ouers geskei is, heg ‘n afskrif van hierdie deel van die egskeidingsdokument aan.
• This section must be completed by a parent, legal guardian or spouse.
• However, if the applicant has been financially self-reliant for a period of 3 years or longer, or if both parents are deceased and he/she does
not have a legal guardian, then the applicant should complete this section.
• If the person receives income from more than one source, please list them all.
• If the income is from wages or a salary, please submit a copy of the latest pay slip with this application.
• If the income is from the profit of a business, please submit a copy of the official financial statement submitted to the tax authorities.
• If the income is from child support as a result of a divorce, please attach a copy of this section of the divorce document.
Naam
Lys u self, u gade, die
applikant en dan die ander
afhanklikes.
Name
List yourself, your spouse,
the applicant and then the
other dependents.
Verwantskap
bv Vrou, seun.
Relation
e.g. Wife, son.
Ouerdom
Dui aan:Voorskool,
Skool, Tersiêr of
Volwassene,ens.
Age Please state:
Preschool, school,
tertiary, dependent
adult, etc.
Indien die persoon nie deel
is van die onmiddellike
familie nie, waarom is die
persoon van u afhanklik?
If the person is not part of
the immediate family, why is
the person dependent on
you?
Het die persoon enige
inkomste uit enige
bron
Meld: Ja of Nee
Does the person have
an income from any
source. State: Yes or
No
Beskrywing van inkomste
bv Werk, Pensioen,
Kinderonderhoud, Rente op
belegging, Besigheidswins,
ens.
Description of income e.g.
Job, Pension, Child grant,
Investment Interest, Business
profit, etc.
Inkomste pm
verkry.
Lewer asseblief
BEWYS.
Income pm
received
Please supply
PROOF.

AFDELING E: DIE NASIONALE KREDIETWET, NR 39 VAN 2005 VERWYS:
SECTION E: THE NATIONAL CREDIT ACT, NO 39 0F 2005 REFERS:
Die Nasionale Kredietwet, nr 39 van 2005, vereis dat studente die volgende twee vrae antwoord:
The National Credit Act, no 39 of 2005, demand that students answer the following two questions:
1. Is u al voorheen deur ‘n hofbevel as sielkundig onbevoeg verklaar?
1. Has any court made an order declaring you mentally unfit?
2. Is u tans onder administratiewe bestuur geplaas?
2. Are you currently placed under administrative management?
JA/YES
JA/YES
NEE/NO
NEE/NO
(Indien u op enige van die vrae hierbo “Ja” geantwoord het, kwalifiseer u, in terme van die kredietwet, nr 39 van 2005, ongelukkig nie vir ‘n beurslening nie.)
(If your answer to any of these two questions is “Yes”, then unfortunately you will not, according to the National Credit Act no 39 of 2005, qualify for a bursary
loan.)
AFDELING F:
SECTION F:
VERKLARING DEUR OUER/VOOG/GADE EN APPLIKANT
DECLARATION BY PARENT/GUARDIAN/SPOUSE AND APPLICANT
Bevestig of weerlê die volgende stelling: / Confirm or negate the following statement:
Ek, die ondergetekende, verklaar hiermee dat die besonderhede deur my in hierdie
aansoekvorm verstrek, waar en korrek is/
I, the undersigned, hereby declare that the information supplied by me in this
application form is true and correct.
JA/YES
NEE/NO
Verder gee ek toestemming dat my persoonlike besonderhede aan maatskappye
verskaf mag word vir beursdoeleindes/
Further I give permission that my personal information may be supplied to companies
for bursary purposes.
JA/YES
NEE/NO
Handtekening van Applikant
Datum
Signature of Applicant _____________________________ Date __________________
Handtekening van Ouer/Voog/Gade
Datum
Signature of Parent/Guardian/Spouse ______________________________ Date __________________
Let Wel: Die bedrag van die beurslening word vasgestel deur ‘n finansiële middeletoets. Indien die student enige addisionele fondse van die universiteit of ‘n
maatskappy ontvang,sal die bedrag van die beurslening ooreenkomstig verminder of selfs gekanselleer word.
Enige addisionele inligting aangaande u omstandighede (finansieel of andersins) kan u in ‘n aparte brief aanheg. Hierdie inligting sal as streng vertroulik
hanteer word.U aansoek sal nie oorweeg word sonder die gesertifiseerde afskrifte van die identiteitsdokumente sowel as stawende dokumente van die
finansiële posisie van die ouer/voog /gade nie.
Please Note: The amount of the bursary loan is determined by a financial means test. If the student receives any additional funding from the university or a
company, the amount of the bursary loan will be accordingly reduced or even cancelled.
Any additional information regarding your circumstances (financial or otherwise) can be attached in a separate letter. This information will be treated as
strictly confidential. Your application shall not be considered without certified copies of the identity documents and supporting documents stating the financial
position of the parent/ guardian/ spouse.
Handtekening van Beursbeampte
Datum
Signature of Bursary Official ______________________________ Date __________________
Handtekening van Data-Kontroleer
Datum
Signature of Data Controller _______________________________ Date __________________