* 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.
2020-21 Rollover Verification Form
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 2020 – 07/23/20 | 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.
Amount of untaxed portions of
Line 4A minus Line 4B $ $
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
• 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.