2017-2018
STUDENT CONTRIBUTION REVIEW FORM


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





SPOUSE NAME
PHONE

Deadline: March 1, 2018

Medical/Dental expenses paid between January 1-December 31, 2017. Do not include expenses covered
by insurance or insurance premiums. Total paid must exceed $3,000.00
• Student (and spouse, if filed separately) 2015 IRS tax return transcript. If either did not file, please complete the
appropriate Non-Filer form and submit with 2015 W-2s and tax filing status letter from the IRS.
• Household Member form listing members of your household as of today.
• Complete the table below; you may attach a spreadsheet if you need additional space.
• Attach paid receipts documenting the medical/dental expenses that you paid in 2017 and were not covered by
insurance. Do not include insurance premiums or unpaid bills.

Natural disaster expenses paid between January 1-December 31, 2017. Do not include expenses covered
by insurance or other agencies.
• Student (and spouse, if filed separately) 2015 IRS tax return transcript. If either did not file, please complete the
appropriate Non-Filer form and submit with 2015 W-2s and tax filing status letter from the IRS.
• Household Member form listing members of your household as of today.
• Complete the table below; you may attach a spreadsheet if you need additional space
• Explanation of the natural disaster (i.e. flood, earthquake, etc.)
• Copy of insurance appraisal and police report (if filed)
• Proof of expenses paid for repairs in 2017 and not reimbursed by insurance

The Financial Aid Office must verify the original 2015 tax information before updating your FAFSA to your 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.

Receipt
Amount
Amount
Number
Provider Name
Total
Expenses
Covered by
Paid in
Insurance
2017
1



2



3




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