* 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
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 2020 – 07/23/20 | Spring 2021 – 11/30/20 | 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.
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.
