WARNING: If you purposely give false or misleading information, you may be fined, sent to prison or both.
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Student Center Building 13
PO Box 1420
Lumberton, NC 28359
T 910.272.3352 Email: finaid@robeson.edu
F 910.272.3314 Website: https://www.robeson.edu/fa/
2020-2021 Pension and IRA
Rollover Form
Student’s Name: _____________________________________________ Student ID: ____________________
Address: __________________________________________ City/State/Zip____________________________
Phone #: ______________________________________ Email: ______________________________________
Pension and Annuity Rollover
The Department of Education has identified a non-zero amount transferred into the untaxed pension or IRA distribution
field reported on your FAFSA. The reported rollover amount has been subtracted from the IRA or Pension distribution
that was transferred from the IRS. The result was used in the calculation of your expected family contribution (EFC).
Please complete the section below to certify that this information is correct.
Yes, I certify that the untaxed pension or IRA distribution transferred from the IRS contained a rollover.
No, I certify that the untaxed pension or IRA distribution transferred from the IRS did NOT contain a rollover.
I certify that the information is true and correct to the best of my knowledge and belief. I understand that RCC has the right
to require additional proof of the information provided on this form. I agree to submitting further documentation if
______________________________________ ___________________
Student Signature Date
______________________________________ ___________________
Parent Signature (for dependent students only) Date
click to sign
click to edit
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