2015 Income Estimate Due To Loss Or Change Of Job Form


Bates College
2015 Income Estimate Due to Loss or Change of Job
You have indicated that you have experienced a change in employment that will affect your income in
2015. Please provide a response for each item shown below. Enter “0” or “N/A” where appropriate. Do
not leave any item blank. The following items must be attached to this form:
1. Most recent pay stub showing new or changed salary
2. Last pay stub from former position
3. Statement of any unemployment benefits received or expected
4. Complete copy of any severance or separation agreement from former employer
Student’s name: ________________________________________________ Student’s Bates ID #: ___________________________
Name of person experiencing a loss of/change in income: ______________________________________________________
When did this change take place?_______________________________________________________________________
2015 Gross Taxable Income
Income Received
Estimated Income
Total Income
Year to Date
(Through Year-End)
(A. + B.)
Wages, salaries, compensation –
(attach copy of last/most recent paystub)
Wages, salaries, compensation –
(attach copy of last/most recent paystub)
Interest and Dividend Income
Net income/loss from business
(S-Corp or sole proprietorship)
Severance Pay (attach copy of severance or
separation agreement from former employer)
Pension/annuity withdrawals
Income from partnerships, estates, trusts
Unemployment compensation
Any other taxable income (please specify)
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