FINANCIAL AID OFFICE
2020-2021 Verification
Untaxed Pension / IRA Form
185 Freedlander Drive | Clyde, NC 28721 | 828.627.4756| fax: 828.627.4513 | hccaid@haywood.edu
Your 2020-2021 Free Application for Federal Student Aid (FAFSA) was selected for review in a process called verification. Federal guidelines
dictate that, before awarding federal student aid, we may ask you to confirm the information reported on your FAFSA. To verify that you
provided correct information, we will compare your FAFSA with the information on this institutional verification document and with any
other required documents. If there are differences, your FAFSA may be corrected. The student and the parent whose information was
reported on the FAFSA (if dependent) must complete and sign this form, attach any required documents, and submit the information to the
Financial Aid Office (FAO). If you have questions, please contact the FAO promptly to avoid delays in the processing of your financial aid.
___________________________________________________ ____________________________
Last Name First Name M.I. HCC ID # or SSN (last 4 digits)
____________________________________________________ ____________________________
Street Address (include apt. no.) Date of Birth
____________________________________________________ ____________________________
City State Zip Code Email Address
____________________________________________________ ____________________________
Home Phone Number (include area code) Alternate or Cell Phone Number
1. Please confirm any Pension/IRA untaxed rollover not reported on the FAFSA.
Note: We may require additional documentation if we have reason to believe that the information regarding the rollover is
inaccurate.
2. CERTIFICATION & SIGNATURES:
If student is classified as dependent, the student and parent whose information was reported on the FAFSA must sign and date.
Each person signing below certifies that all of the information reported is complete and correct.
_______________________________________________ ______________________
Print Student Name HCC ID # or SSN (last 4 digits)
_______________________________________________ ______________________
Student Signature Date
_______________________________________________ ______________________
Parent Signature (if dependent) Date
WARNING! If you purposely give false or misleading information, you may be fined, imprisoned, or both.
Note: Please allow four weeks for processing.
As of the day you filed your FAFSA, what is your (and spouse’s) total amount of
untaxed pension/IRA rollover. Review lines 4a and 4b on Form 1040. Include copies
of 1099R form for 2018.
Include parents’ amounts
below if the information
was required on your
FAFSA.
As of the day you filed your FAFSA, what is your parents’ amount of untaxed
pension/IRA rollover. Review lines 4a and 4b on Form 1040. Include copies of 1099R
form for 2018.
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