SECONDARY

SCHOOLS BURSARY FORM

REPUBLIC OF KENYA

COUNTY GOVERNMENT OF SIAYA

DEPARTMENT OF EDUCATION, YOUTH AFFAIRS, GENDER AND SOCIAL
SERVICES
SIAYA COUNTY EDUCATION BURSARY FUND (SCEBF)
Email: [email protected]

BURSARY APPLICATION FORM-FY 2024/2025

ONLY FORM 1, 2 AND 3 TO APPLY

INSTRUCTIONS
1. Incomplete SCEBF Bursary Application form will not be processed
2. This form must be filled in BLOCK LETTERS.
3. Each Applicant MUST attach a certified copy of his/her institution’s fees
statement. Newly admitted students should include a copy of the Admission
letter.
4. Each Applicant MUST ensure to fill in correct institutional Email Addresses,
Bank Details of the institution i.e. bank name, branch and account
number. In addition, provide a working mobile number of the institution.
5. For continuing Students, ensure you attach a copy of the previous term’s
Report Form (Mandatory).
6. For Form One students, ensure you attach a copy of your primary school
leaving certificate and result slip.
7. For Total and Partial Orphans, ensure that you attach copies of Death
Certificates, Burial Permit or a letter from your area Chief.
8. For students with Disability, a letter explaining the nature of disability from a
Chief, Assistant Chief, Head teacher, Government medical Officer or Religious
leader.
9. It is important that the SCEBF Applicant declares other bursary Fund Support
he/she is currently receiving.
10. The Applicant must only apply in his/her Ward. Double application will
be rejected in totality.

1
 SECONDARY
SCHOOLS BURSARY FORM
11. The filled form should be returned to the Ward Administrator’s office
latest by 22nd November, 2024 at 4.00 pm and should be acknowledged by
the ward office.

NB: Forgery and making of illegal rubberstamps are criminal offences

and any applicant who commits such offences shall be charged in a
court of law.

: Applicants with multiple applications will not benefit

PART 1: GENERAL INFORMATION (Use block letters)

Year of Application…………………………County………………………………. Sub-
County………………………………

Ward………………………………………Sub-Location………………………………………
Village………………………………

PART 2: STUDENT PERSONAL DATA:

(a) Student’s
Name…………………………………………………………………………………………………………
……
Surname First Middle
(b) Sex: Male Female (Tick one only)
(c) Year of Birth………………… Month…………………Day…………………….
(d) Disability (if any): State Type…………………………………………………….
(e) Father’s name…………………………………………….ID NO………………………..Mobile
NO………………………
(f) Mother’s name……………………………………………IDNO…………………………Mobile
NO……………………..
OR
(g) Guardian’s name………………………………………………….ID NO…………………Mobile
NO………………
(h) Relationship to the Guardian…………………………………………
(i) Who pays for your fees: (i) Father (ii) Mother (iii) Guardian
(iv) A well-wisher (v) sponsor (Tick one only)

PART 3: EDUCATION DATA/INSTITUTION DETAILS

(a) Name of Secondary School

…………………………………………………………………………………………………

2
 SECONDARY
SCHOOLS BURSARY FORM
(b) P.O BOX………………………………......Tel/Mobile No………………….. Email Address:
……………….........
(c) Year of Admission…………………….. Admission
No……………………..Form/Class…………………
(d) Category of School National County Sub-County (Tick as
appropriate)
(Attach Evidence i.e. either admission letter or report form)

PART 4: FEES PAYABLE FOR THE YEAR

(a) Total Fees Payable………………………………… Balance
………………………………………….
(b) Total Fees Paid……………………………………… Balance
………………………………………….
(c) Amount applied
for………………………………………………………………………………………….
(Attach certified copy of current fee structure) or fees balance statement duly certified by
the Principal)

PART 5: FAMILY STATUS INFORMATION

(a) Both Parents alive: (d) Both Parents Deceased
(b) One Parent Alive (e) Disabled Parent
(c) Single Parent (Tick one only)

(Attach a death certificate /burial permit or Letter from Chief or Assistant Chief. For
option (e), please attach necessary documents as evidence of Disability)

Family’s main source of income :……………………………………Total income per Year

KSH…………………

State why you are not able to pay your child’s school fees
…………………………………………………………………………………………………………………………
……………………

(g)OTHER SIBLINGS IN SCHOOL/COLLEGES/UNIVERSITY

Name of student Institutio Form/ Total/ Paid Balance

n Year Fee(Ksh) ( Ksh) (Ksh)

3
 SECONDARY
SCHOOLS BURSARY FORM

Total Fee Burden Per year

PART 6: STATUS OF BURSARY RECEIVED (If any)

(a) How much SCEBF Bursary did you receive in the last financial year?
Ksh…………………………………
(b) Are you a beneficiary of any other Bursary Scheme? (i) Yes (ii) No (tick one
only)
(c) If yes, specify (i)………………………………… (ii)
…………………………………………………………………………
(d) How much did you receive from (c) above, last financial year?
Ksh……………………………………….

PART 7: VERIFICATION, DECLARATION AND RECOMMENDATION

(A) STUDENT’S DECLARATION:

I declare that the information given above is true:

Name………………………………………………………Signature………………….Date……………
Mobile No………………

(B) PARENT’S/GUARDIAN’S DECLARATION

I declare that I have read this form or this form has been read to me and hereby confirm
that information given is true.

Name………………………………………Signature/thumbprint……………………Date:……………
Mobile No……………..

(C) IMMEDIATE PRIMARY SCHOOL HEAD TEACHERS’S DECLARATION (THOSE

JOINING FORM ONE)
(I)Year of Admission……………… KCPE Result: Marks…………………..Grade…………………….
(ii) Discipline: Excellent Very Good Good Fair Poor
(iii) Recommendation on level of need, Discipline and Academic performance:
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………
I declare that the above named was a pupil in this school and the information given is true

4
 SECONDARY
SCHOOLS BURSARY FORM
Name ………………………………………….. Signature …………………Date……………..Mobile
No……………………..

D) PRINCIPAL’S DECLARATION

(I) Year of Admission……………………………...

(II) Position in class/Form: Term I ……………… Term II ……………………. Term

III………………… (Certify the attached copy of the report form)

Excellent: Very Good Average Below Average

(iii)Total Fees Outstanding Ksh………………………………………………………………………

(iv) Student’s Discipline:

Excellent: Very Good Good Fair poor (Tick one option

only)

(v) Principal’s comments on the level of need, Discipline and academic Performance.

…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………
…………………………………………………………………………………………………………………………
………………………..
Account particulars:

Name of bank: ……………………………………Branch:……………….. Account number:

…………………………….

NB: PLEASE NOTE THAT THIS IS VERY IMPORTANT FOR WIRING FUNDS FOR
SUCCESSFUL APPLICANTS. NO CHEQUES WILL BE ISSUED.

I confirm that the School/institutions is registered by the Ministry of Education

Reg. No ……………………………. and that the above named is a student in this school and
that the information given above is true.

Name…………………………………………Signature…………………………Date…………………
Mobile No………………

Schools’ Email Address: ……………………………………………… Rubber

stamp…………………………………………..

E) CHIEF/ ASSISTANT CHIEF’S OR RELIGIOUS LEADER’S REMARKS ON THE STATUS

OF THE FAMILY/PARENTS AND DISABILITY OF THE STUDENT (if any)

5
 SECONDARY
SCHOOLS BURSARY FORM
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
……………………………………………………

(i) Certify that the information given above is true

Name…………………………………………………Signature…………………………Mobile
No…………………

Date/stamp……………………

PART F: DECLARATION BY THE WARD EDUCATION BURSARY FUND.

(c) Total Score as a Percentage

(d) General remarks ……….

………………………………………………………………………………………………

RECOMMENDATION:

PART A

i. Not Deserving
ii. Deserving
iii. Most deserving and require assistance

Reason(s)
…………………………………………………………………………………………………………………………
……

…………………………………………………………………………………………………………………………
…………………..

Signed:

CHAIRMAN:

Name……………………………………………….Signature…………………………
Date……………………

SECRETARY:

Name………………………………………………Signature…………………………
Date……………………………………

PART B: DECLARATION BY THE SIAYA COUNTY EDUCATION BURSARY COMMITTEE

REMARKS (IF ANY)

……………………………………………………………………………………………………………

6
 SECONDARY
SCHOOLS BURSARY FORM
…………………………………………………………………………………………………………………………
……………..

RECOMMENDATION

(I) Not deserving

(II) Deserving
(III) Most deserving and requires assistance

Reason(s)
…………………………………………………………………………………………………………………………
…………

…………………………………………………………………………………………………………………………
………………………..

CHAIRMAN:

Name………………………………………………………………Signature…………………………………
Date……………………

SECRETARY:

Name……………………………………………………………..Signature…………………………………….
Date………………