2020-2021 VerificationofPensionand/or Annuity Rollover
Financial Aid Office, P.O. Box 917, Henderson, NC 27536
Telephone: (252) 738-3280, Fax: (252) 738-3388, Email: fao@vgcc.edu
Student Name: __________________________________ Student ID#: __________________
(Print full name)
The U.S. Department of Education has identified a non-zero amount transferred into the untaxed pension
or IRA distribution field reported on your FAFSA. The reported rollover amount has been subtracted from
the IRA or Pension distribution that was transferred from the IRS. The result was used in the calculation of
your expected family contribution (EFC), which assists in the determination of any eligibility for financial
Please provide the following information for student/parent.
I certify that the untaxed pension or IRA distribution transferred from the IRS contained a rollover.
By signing this Verification of Pension and/or Annuity Rollover form, I understand that if I give
false or misleading information I may be subject to a $20,000 fine, to a prison sentence, or to
Student Signature: ______________________________________ Date: __________________
Parent Signature: _______________________________________ Date:__________________
(If considered dependent, parent must sign)
2020-2021 Verification of Pension/Annuity Rollover
Revised Date: 06/08/2020/FAO