2017-2018
STUDENT CONTRIBUTION REVIEW FORM
Change in Income or Benefits


_________________________________ __________________ ___________________@mymail.mines.edu
STUDENT NAME (PRINT CLEARLY) CWID NUMBER
EMAIL ADDRESS





SPOUSE NAME (IF APPLICABLE)
PHONE


Deadline: March 1, 2018

Loss of employment or reduction in earnings for at least an eight-week period
• If your income change occurred before January 1, 2017 and is anticipated to continue through 2017, complete Table A
on page 2 to report your 2016 income. If your income change occurred after January 1, 2017, complete Table B on
page 2 to report your projected 2017 income.
Please provide the following documents:
• Signed and dated statement about what changed in your financial circumstances. Include your CWID.
• Submit student (and spouse if filed separately) 2015 IRS tax return transcript. If either did not file, please
complete the Non-Filer form, tax filing letter from the IRS, and submit with necessary 2015 W-2s. Write the
student’s CWID on all pages.
• Submit Household Member form listing members of your household as of today.
• If this appeal is submitted after January 31, 2017 for changes in 2016, include 2016 IRS tax return transcript(s). If
this appeal is submitted after January 31, 2018 for changes in 2017, include 2017 IRS tax return transcript(s).
• Statement from your current employer on letterhead listing the beginning date of employment, average monthly
earnings, and a current paycheck stub. If you are not currently employed, provide a statement to that effect.
• Statement from previous employers on letterhead listing last date of employment and average monthly earnings,
with the last paycheck stub received.
• If applicable, unemployment benefit statement for total benefits received in 2016 or 2017.
• If unemployment benefits have ceased, provide a cancellation statement from the agency stating the last date
benefits were received and the total amount received in 2016 or 2017.

Decrease or loss of benefits (i.e., Taxed Social Security, Unemployment Compensation) in 2016

Please provide the following documents:
• Student (and spouse, if filed separately) 2015 IRS tax return transcript. If either did not file, please complete the
appropriate Non-Filer form, tax filing letter from the IRS, and submit with 2015 W-2s.
• Household Member form listing members of your household as of today.
• Statement from the benefit provider listing the date of benefit reduction or termination.
• Statement of benefits for 2015 and total received in 2016.

Decrease in child support received OR increase in child support paid to ex-spouse in 2016

Please provide the following documents:
• Student (and spouse, if filed separately) 2015 IRS tax return transcript. If either did not file, please complete the
appropriate Non-Filer form, tax filing letter from the IRS and submit with 2015 W-2s.
• Household Member form listing members of your household as of today.
• Divorce decree and addendum to the decree indicating the change in payments and/or county court pay history
reports for 2015 and 2016.

The Financial Aid Office must verify the original 2015 tax information before updating your FAFSA to your 2016 or
2017 information. All documentation must be provided before your review request will be processed. If you have
other extenuating circumstances we should consider, please contact our office for additional information.



Student’s CWID ____________
Table A
Use this table if the change happened in 2016
INCOME
ACTUAL 2015
ACTUAL 2016
Annual Work Income: Student


Annual Work Income: Spouse


Withdrawal from Retirement Accounts


Child Support Received


Interest/Dividend Income


Social Security Income for all Family
Members


Unemployment Compensation


Disability Income


Support from family


Severance


Other


TOTAL INCOME


If the total income for 2016 is more than 2015, you are not eligible for a review.

Table B
Use this table if the change happened in 2017
INCOME
ACTUAL 2015
PROJECTED 2017
Annual Work Income: Student


Annual Work Income: Spouse


Withdrawal from Retirement Accounts


Child Support Received


Interest/Dividend Income


Social Security Income for all Family
Members


Unemployment Compensation


Disability Income


Support from family


Severance


Other


TOTAL INCOME


If the projected income for 2017 is more than 2015, you are not eligible for a review.

I certify that the information provided is true and that false or misleading information will be cause for repayment of
financial aid funds received. Due to limited funding, approval of a Contribution Review does not guarantee that additional
funds will be awarded.





STUDENT SIGNATURE
DATE


Return this form and required documentation to the Mines Financial Aid Office
finaid@mines.edu
Ben Parker Student Center, Golden, CO 80401
Phone: (303) 273-3301 or 888-446-9489 • Fax (303) 384-2252


Document Outline