Financial Aid & Scholarships
1700 Spartan Drive, Elgin, IL 60123-7193
Phone: 847-214-7360 Fax: 847-608-5460
2020-2021 Student IRA/Pension Rollover Verification Form
Student Name: ____________________________________ ECC ID or SSN: _______________________
You indicated on your 2020-2021 FAFSA an amount of untaxed IRA or pension distributions received in 2018.
The untaxed portion of an IRA or pension distribution must be reported as untaxed income on the FAFSA unless
it was a rollover into another qualified retirement plan.
Please review your 2018 federal tax return and complete the section below. Indicate the amount which was
rolled over into another qualified retirement plan. If the answer is none, please write zero.
Untaxed IRA or Pension Distribution may be calculated using: IRS Form 1040 (line 4a minus 4b)
Total from 2018 Federal Tax
Amount of Total that was a
Untaxed IRA or Pension Distributions
** If you indicated that some funds were rolled over, please provide a copy of the IRS Form 1099-R to
verify the amount that was rolled over.
I certify that all of the information on this form is complete and correct.
Student Signature: _
* Electronic Signatures will not be accepted
_________________________________ Date: _______________________