IRA/Keogh Follow-Up Form 2019-2020
(Student)
STUDENT NAME: _____________________________________ DATE: ______________
The Office of Financial Aid at Purdue University Northwest will request this documentation only if it is needed to
complete your financial aid file.
DIRECTIONS: Complete this form and return the signed form to the Office of Financial Aid.
The IRS Tax Transcript you provided indicates you (and/or your spouse, if married) received an
IRA/Keogh distribution in 2017 Further processing of your financial aid will not occur until the
information requested below has been received by the Office of Financial Aid.
According to your IRS Tax Transcript, you (and/or your spouse,
if married) received an IRA/Keogh distribution in 2017
Was there a rollover?
If YES, please indicate the rollover amount.
Rollover?
Yes
No
$
Student/Spouse
Rollover Amount
CERTIFICATION: (Provide required signatures and PUID)
Sign and date this form certifying that the information provided is complete and correct. If parent signature was
required on your FAFSA, at least one parent must sign.
Student Signature: ______________________________________ Date: ____________
PUID: ______________________________________________
Spouse Signature: ________________________________________ Date: ____________
Office Use Only – RRAAREQ: ______IRAS20 (R)
Hammond Campus
2200 169th Street * Hammond, IN 46323
(219) 989-2301 * FAX: (219) 989-2141
Westville Campus
1401 S. U.S. Hwy. 421 * Westville, IN 46391
(219) 785-5460 * FAX: (219) 785-5653
Toll-Free: 1-855-608-4600
website: pnw.edu
