2015 Income Estimate Due To Loss Or Change Of Job Form printable pdf download

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 –

Father/Stepfather

(attach copy of last/most recent paystub)

Wages, salaries, compensation –

Mother/Stepmother

(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)

Page 1

2015 Income Estimate Due To Loss Or Change Of Job Form