Date of receipt
Attachment no. 5 to the Financial Support Regulations
First name and surname………………………..…………………………………………………………….
Faculty and year of studies………………………………………………………………………………
Student no.……………………………….………
INCOME RECALCULATION APPLICATION
to the Department Bursary Committee of MUB
I hereby apply for a recalculation of my family's members' income in the current calendar year due to:
1.
a loss of income1 by a member of my family (give name and surname and the degree of relationship)
…………………………..…………………..…….…… ………………………, documented by the following attachments:
…………………………………………………………………………………….……..………………………………………
…………………………………………………………………………………………………………………………………...
2.
a gain of income2 by a member of my family (give name and surname and the degree of relationship)
……………………………………………………………………………………, documented by the following attachments:
…………………………………………………………………………………………………………………………………..
Ad. 1 Documents specifying the date of income loss and a monthly amount of the lost income need to be submitted
Ad. 2 A document specifying the amount of income received by a family member and the number of months in which the income was
received need to be submitted
1
i2
According to the November 28, 2003 Family Benefits Act art. 3 pt. 23 and 24 as amended (Dz. U. of 2006 no. 139 pos. 992)
2
I hereby declare that I am aware of the criminal responsibility for making a false statement.
Białystok, date …………………………..
…………………………………………….
doctoral student's signature
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The November 28, 2003 Family Benefits Act art. 3 pt. 23 and 24 as amended.
Each time the Act mentions:
23) a loss of income – this means a loss of income caused by:
obtaining the right to parental leave,
losing the right to an allowance aid or bursary for the unemployed,
losing work or another gainful employment, excluding work performed on the basis of a contract of specified work,
losing pre-retirement benefits, teacher's compensatory benefits, as well as pension or family or social pension, excluding pension awarded farmers due
to transfer or lease of farms,
deregistration of a non-agricultural economic activity,
losing sickness benefits, rehabilitation benefits or maternal benefits one is entitled to after losing work or another gainful employment,
losing court-ruled alimony due to the death of the person obliged to pay these benefits.
24) a gain of income – this means a gain of income caused by:
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the end of parental leave,
obtaining the right to an allowance aid or bursary for the unemployed,
gaining work or another gainful employment, excluding work performed on the basis of a contract of specified work,
obtaining pre-retirement benefits, teacher's compensatory benefits, as well as pension or family or social pension, excluding pension awarded farmers
due to transfer or lease of farms ,
starting a non-agricultural economic activity,
gaining sickness benefits, rehabilitation benefits or maternal benefits one is entitled to after losing work or another gainful employment.