Office use only Code RLOVSO/ FA ROLLOVER STU ODD
2020-2021 Rollover - Student
SECTION A: STUDENT INFORMATION
Student Name: MC ID#:
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 Return / Transcript as
Untaxed Portions of IRA Distribution and Pensions.
SECTION B: 2018 FEDERAL TAX FORM 1040 ROLLOVER
Did you (Student) and/or spouse (if married) have untaxed income from either of the
following on 2018 tax return(s)? (Hint: 1040 line 4a-4b and/or line 4c-4d)
Rollover amount, if any: $
Yes
Rollover amount, if any: $
If Yes, please attach all of your (student) and/or spouse’s
(if married), 2018 1099 R
statement(s)
.
Did you and/or spouse (if married) receive Form 5329 from a financial institution for
Rollover to a Traditional IRA?
No Yes
If Yes, please attach the form 5329.
I / We understand that this form must be signed and submitted with all other requested
documents before my financial aid will be processed. Each person signing below certifies that
all of the information reported is complete and correct.
WARNING: If you purposely give false or misleading information, you may be fined, sent to
prison, or both.
Electronic signatures are not acceptable.
Student Signature: _____________________________ Date: __________________
Spouse Signature (if needed): _____________________ Date: _________________
