* This form must be submitted by the priority deadline to ensure a determination of eligibility before the Fee Due Date. Students may still apply
for aid after the priority deadlines, but EFSC cannot guarantee that late submissions will be notified of aid eligibility prior to the Fee Due Date.
01/27/20
21ROLP
FA Verification
2020-21 Parent Rollover Verification Form
Dependent Student
The Office of Financial Aid needs to verify information provided on your 2020-21 Free Application for Federal Student
Aid (FAFSA). You or your parent(s) indicated on your FAFSA that your parent(s) had a qualifying IRA and/or Pension
Distribution Rollover in the 2018 tax year. Further information about this transaction is required to process your
financial aid application.
Priority Deadlines*: Fall 202007/23/20 | Spring 202111/30/20 | Summer 2021 – 04/22/21
A. Student Information
B#
Last Name First Name M.I. Student ID
B. Untaxed IRA Distribution or Pension Rollover
1. Enter the amount from the parent’s applicable 2018 IRS Federal Income Tax Return.
Do not leave any field blank. Enter “N/A” if an item is not applicable.
2018 IRS TAX FORM 1040
Untaxed Amount Defined
Untaxed Amount
Rollover Amount
Amount of untaxed portions of
IRA distributions
Line 4A minus Line 4B $ $
2. Documentation
Provide one of the forms of documentation listed below with this form:
A copy of the parent’s 2018 IRS Form 1099-R
A copy of the parent’s 2018 IRS Form 5498
A copy of the parent’s 2018 Wage & Income Transcript received from the IRS
IRS Wage & Income Transcripts can be requested online, by mail, or by phone:
To order online, go to www.irs.gov and click on "Get Your Tax Record." Then click on “Get
Transcript Online.”
To order by phone, call 800-908-9946 and follow the prompts.
To order by mail or fax, complete IRS Form 4506-T.
C. Certification and Signatures
One parent whose information was reported on the FAFSA must sign
and date. By signing below, you certify that all of the information
reported is complete and correct.
Parent’s Original Signature (cannot be signed electronically) Date
WARNING: If you purposely give false
or misleading information, you may be
fined, sent to prison, or both.
phillips
wendy
n
51.00
651.00
02/20/20
EFSC Office of Financial Aid
www.easternflorida.edu/go/aid | (321) 433-7339 | finaid@easternflorida.edu
2
D. Document Submission
You may submit this document by the following methods:
1. EFSC DOCUMENT DROPBOX (RECOMMENDED)
Print and complete this document (including the original signatures), scan the document, and upload the
document via the Document Dropbox in myEFSC. Printers and scanners are available in EFSC’s open
computer labs and libraries.
2. IN PERSON
Submit your document in person at the Office of Financial Aid on any campus:
Cocoa
Building 11, Room 209
Monday through Thursday, 8 a.m. to 7 p.m.
Palm Bay
Building 1, Room 117
Monday through Thursday, 8 a.m. to 7 p.m.
Melbourne
Building 1, Room 137
Monday through Thursday, 8 a.m. to 7 p.m.
Titusville
Building 3, Room 125
Monday through Wednesday, 8 a.m. to 5:30 p.m.
Thursday, 8 a.m. to 7 p.m.
3. BY MAIL
Mail your document to the Office of Financial Aid on any campus:
Cocoa
Eastern Florida State College
Office of Financial Aid, C11-209
1519 Clearlake Road
Cocoa, FL 32922
Palm Bay
Eastern Florida State College
Office of Financial Aid, PB1-117
250 Community College Parkway
Palm Bay, FL 32909
Melbourne
Eastern Florida State College
Office of Financial Aid, M1-137
3865 N. Wickham Road
Melbourne, FL 32935
Titusville
Eastern Florida State College
Office of Financial Aid, T3-125
1311 N. US 1
Titusville, FL 32976
QUESTIONS?
Financial Aid Specialists are available at the campus locations listed above, by phone at 321-433-7339, and via e-mail at
finaid@easternflorida.edu.
Eastern Florida State College is committed to equal access/equal opportunity in its programs, activities, and employment. For
additional information, visit Eastern Florida State College: easternflorida.edu/go/equity.