A. Student’s Information
Student’s Last Name Student’s First Name Student’s M.I. Student’s HCC ID Number
2018/2019
Independent IRA/Pension Rollover Form
Distributions from pensions, annuities, and other similar accounts are usually reported to you on IRS Form 1099-R.
Federal regulations state that if you receive a lump-sum distribution, you can roll over the distribution into another qualied
retirement plan or IRA and retain the tax-deferred status.
Please complete this form if all or some of an IRA or Pension has been rolled over. Untaxed IRA distributions are
calculated using the dierence between lines 15a and 15b of IRS form 1040 or lines 11a and 11b of IRS form 1040A.
Untaxed pension/annuity distributions are calculated using the dierence between lines 16a and 16b of IRS form 1040 or
lines 12a and 12b of IRS form 1040A. Please review your individual tax return, complete the table below, and send the
completed form to Financial Aid Services after attaching the 1099 and/or investment documents conrming the rollover.
B. Rollover Information
The 2018/2019 FAFSA uses information from your 2016 taxes.
Which taxpayer had a rollover distribution in 2016? Student Spouse of Student
Distribution Type Total Amount Taxable Amount Untaxed Amount
Amount of Untaxed
Portion Reinvested
IRA Distribution(s) $ $ $ $
Pension/Annuity
Distribution(s)
$ $ $ $
C. Rollover documentation
I have attached a 1099 and/or other investment documents to conrm the rollover.
Financial Aid Services
10901 Little Patuxent Pkwy
Columbia MD 21044
443-518-1260; 443-518-4576 (FAX)
naid@howardcc.edu
www.howardcc.edu
CRI: FAC18ROI
ImageNow:
Doc type: UG Finaid Verication
FA Doc Name: V-Verication Forms
Work Flow:
Main: FAS Document Processing
Sub-queue: Academic Year
D. Certication and Signature
I certify that all of the information reported is complete and correct.
Student Signature Date
