______________________________________ ______________________________ ______________________________
Financial Aid Office
2019-2020 Pension and Annuity Rollover Worksheet
Student’s Name Student ID
Complete this form if all or some of your or your parent's IRA or Pension has been rolled over (or your spouse’s if you are
married), and the rolled over amount is showing on your 2019-20 FAFSA as untaxed IRS distributions or untaxed pensions.
Federal Regulations state that if you receive a lump-sum distribution from a pension, annuity, profit-sharing or retirement
plan, IRA, Insurance contract, etc., you can roll over the distribution into another qualified retirement plan or IRA and keep it
in a tax-deferred status. These rolled over funds should not be reported on the FAFSA as untaxed income, however if you used the
IRS Data Retrieval Tool when completing the FAFSA, the retrieval tool would not recognize the rollover.
IRA distributions are taken from lines 15a and 15b of the IRS form 1040 or lines 11a and 11b on the 1040A. The Pensions and
Annuities are taken from lines 16a and 16b of the IRS form 1040 or lines 12a and 12b of the IRS form 1040A. Please review your
individual tax return, and indicate if all or some of the distribution was reinvested.
Attach documentation from the financial institution handling the investment to show the amount reinvested or submit
your 1099-R for 2017.
Type of Distribution
on Tax Return
Total Amount Taxable Amount Untaxed Amount Amount of
IRA Distributions $ $ $
Some $
Pensions and Annuities $ $ $
Some $
By providing signatures, you are certifying that all of the information on this form is complete and correct. You are also authorizing
CCC&TI to make corrections to your original and/or subsequent applications based on the documents you are now submitting.
Student’s Signature Date
Parent(s) Signature Date
Warning: According to the U.S. Department of Education, ifyou purposely give false or misleading information on this
form, you may be subjectto a fine of up to $20,000 or imprisonment for up to 5 years, or both.
Please return this completed worksheet to:
Caldwell Campus
Watauga Campus
2855 Hickory Blvd
P.O. Box 3318
Hudson, NC 28638
Boone, NC 28607
Fax: 828.726.2709
Fax: 828.297.1729
Email: finaid@cccti.edu
Email: finaid@cccti.edu
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