Fillable Rlovse Rollover – Student

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Rlovse Rollover – Student

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Office of Student Financial Aid
Phone : (240)567-5100
Email: FinancialAid@montgomerycollege.edu
PRINT
M
Office use only Code RLOVSE / FA ROLLOVER STU EVEN
2019-2020 Rollover – Student
SECTION A: STUDENT INFORMATION
Student Name:
MC ID#
Section B: 2017 Federal Tax IRA Rollover
Please provide all of your (and or your spouse’s if married) 2017, 1099R statement(s).
SECTION C: CERTIFICATION
I / We certify that all the information contained on this form is complete and correct. NOTE: If you purposely give
false or
misleading information, you may be imprisoned and/or fined up to $25,000. I / We
understand that this form
must be signed and submitted with all other requested documents before my financial aid will be processed.
Electronic signatures are not accepted.
Student Signature (must be signed in ink) Date
_____________________________________ _________
Spouse Signature (must be signed in ink) Date
Office Use Only
_______________ Box 1 amount
_______________ Box 2a amount
_______________ Box 1 minus Box 2a
_______________ Box 7, if code G and/or H, report difference of box 1 minus box 2a
During the Data Retrieval Tool (DRT) process, an amount greater than zero was transferred into the FAFSA or
an amount greater than zero appears on your Tax Transcript as Untaxed Portions of IRA Distribution field or
the Untaxed Portion of Pensions.
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Rlovse Rollover Student

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Completed 7 April 2020

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