There will be no change to the Form 1099-R itself. If the financial institution accepts your self-certification that you would qualified for a waiver of the 60-day deadline, the distribution is simply reported on your tax return as having been rolled over, the same as if you had rolled it over within 60-days. If the rollover is to an IRA, the financial institution will include the notation "SC" in box 13c of the Form 5498 that reports the rollover contribution, but this doesn't have any bearing on your tax return.
