A. Student’s Information
Student’s Last Name Student’s First Name Student’s M.I. Student’s HCC ID Number
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.
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 complete sections B, C, and D, below, and send the signed form to Financial Aid Services.
B. Rollover Information
Student had a rollover distribution in 2017. Yes No
Spouse had a rollover distribution in 2017. Yes No
To assist you in calculating the rollover, use the 20171099 R, 2017 Wage & Income transcript, or 2017 1040 tax return.
Distribution Type Total Amount Taxable Amount Untaxed Amount
Amount of Untaxed
Portion Reinvested
IRA Distribution(s) $ $ $ $
Pension/Annuity
Distribution(s)
$ $ $ $
C. Rollover documentation (optional)
I have attached a 2017 1099-R, 2017 Wage & Income transcript or 2017 signed tax return 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: FAC19ROI
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
Each person signing below certies that all of the information reported is complete and
correct. If student is dependent, the student and one parent whose information was reported
on the FAFSA must sign and date.
Student Signature Date
2019/2020 Independent IRA/Pension Rollover Form
