* 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.
FA Verification
2020-21 Rollover Verification Form
Independent Student
The Office of Financial Aid needs to verify information provided on your 2020-21 Free Application for Federal Student
Aid (FAFSA). You indicated on your FAFSA that you 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 2021 – 11/30/20 | Summer 2021 – 04/22/21
A. Student Information
Last Name First Name M.I. Student ID
B. Untaxed IRA Distribution or Pension Rollover
1. Enter the amount from your 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 your 2018 IRS Form 1099-R
A copy of your 2018 IRS Form 5498
A copy of your 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
By signing below I certify that all of the information reported is
complete and correct.
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.
EFSC Office of Financial Aid
www.easternflorida.edu/go/aid | (321) 433-7339 | finaid@easternflorida.edu
D. Document Submission
You may submit this document by the following methods:
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.
Submit your document in person at the Office of Financial Aid on any campus:
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.
Building 1, Room 137
Monday through Thursday, 8 a.m. to 7 p.m.
Building 3, Room 125
Monday through Wednesday, 8 a.m. to 5:30 p.m.
Thursday, 8 a.m. to 7 p.m.
Mail your document to the Office of Financial Aid on any campus:
Eastern Florida State College
Office of Financial Aid, C11-209
1519 Clearlake Road
Palm Bay
Eastern Florida State College
Office of Financial Aid, PB1-117
250 Community College Parkway
Palm Bay, FL 32909
Eastern Florida State College
Office of Financial Aid, M1-137
3865 N. Wickham Road
Eastern Florida State College
Office of Financial Aid, T3-125
1311 N. US 1
Titusville, FL 32976
Financial Aid Specialists are available at the campus locations listed above, by phone at 321-433-7339, and via e-mail at
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.
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