Form Uben 142Cap – Fill Out and Use This PDF

Read the Special Tax Notice for UC Retirement Plan Distributions (available at ucal.us/specialtaxnotice) before electing a distribution.

All references to CAP below refer to the Capital Accumulation Payment (April 1992–July 1994) and the Capital Accumulation Payment II (April 2002 and April 2003).

Use this form to elect a distribution of your CAP balance, unless you are electing retirement income or a lump sum cashout. CAP distributions are incorporated into the monthly retirement income or lump sum cashout election process.

Use this form to chose one of the following payment options for this distribution:

•To have your entire CAP balance paid to you.

•To arrange for a direct rollover of your entire CAP balance to an IRA or to an employer plan (including UC’s Deined Contribution Plan (DC Plan), Tax Deferred 403(b) Plan (403(b) Plan), or 457(b) Deferred Compensation Plan (457(b) Plan)).

•To arrange for a direct rollover of part of your CAP balance ($500 minimum) and to have the remaining balance paid to you.

	1. PERSONAL INFORMATION			(See reverse for Privacy Notiications)
	NAME (Last, First, Middle Initial)	SOCIAL SECURITY NUMBER			BIRTHDATE
	MAILING ADDRESS (Number, Street)				DAYTIME PHONE
					(	)
	(City, State, ZIP, Country)			CHECK THIS BOX IF PERMANENT	SEPARATION DATE
				ADDRESS CHANGE
	CITIZENSHIP—Check the box that applies:

2. CAP BALANCE DISTRIBUTION INSTRUCTIONS

I elect the following payment option for my CAP distribution (choose one only):

To have my entire CAP balance made payable to me at the mailing address in Section 1 above. (Go to Section 5.)

A direct rollover of part of my CAP balance in the amount of $_________________ (must be at least $500) to my account in the UC

Retirement Savings Program (RSP) plan checked in Section 3 below, with the balance made payable to me. (Complete Sections 3 and 5.)

A direct rollover of my entire CAP balance to my account in the UC RSP plan checked in Section 3 below. (Complete Sections 3 and 5.)

A direct rollover of my entire CAP balance to an IRA or to an employer’s (other than UC’s) qualiied 401(a), 401(k), 403(b) or governmental 457(b) Plan that will accept my rollover. (Complete Sections 4 and 5.)

A direct rollover of part of my CAP balance $_________________ (must be at least $500) to an IRA or to an employer’s (other than

UC’s) qualiied 401(a), 401(k), 403(b) or governmental 457(b) Plan that will accept my rollover and the balance paid to me. (Complete Sections 4 and 5.)

I understand that for any distribution that is made payable to me and is eligible for rollover, UC must withhold 20% of the taxable portion for federal taxes and will also withhold 2% for California state taxes, unless I check the box below. (California state taxes are not withheld from payments sent to a mailing address outside California.)

Do not withhold California state tax.

3. ROLLOVER TO UC PLAN INSTRUCTIONS

A direct rollover of all or part of your CAP balance may be made to UC’s DC Plan, 403(b) Plan, or 457(b) Plan if your resulting balance in the plan you choose equals at least $2,000.

UC will transfer the amount of your rollover electronically to Fidelity Retirement Services and a check will not be sent to you. Your UCRP rollover will be invested according to your investment elections on ile at Fidelity Retirement Services. You can view or change your investment elections at ucfocusonyourfuture.com. (Under “My Account” select “Request Investment Changes,” and then select “Contribution Amount.”) Or you can speak to a Fidelity Retirement Specialist by calling the toll-free number 1-866-682-7787, Monday through Friday, 5:00 a.m. to 9:00 p.m., PT. If you have no investment elections on ile, your UCRP rollover will be invested in the plan’s default fund; contact Fidelity Retirement Services directly to change your investment elections or to move some or all of your existing account balances (called performing an “exchange”). You should also review and, if necessary, update your beneiciary designations for these plans at ucfocusonyourfuture.com or contact Fidelity at 1-866-682-7787.

4. ROLLOVER TO IRA OR QUALIFIED PLAN INSTRUCTIONS

If you are electing a direct rollover to an IRA, complete section A, “IRA Certiication.” If you are electing a direct rollover to an employer plan, complete section B, “Qualiied Plan Certiication.” (Complete A or B only.) In either case, UC will make the check payable to the recipient IRA or plan and will send it to you at the mailing address in section 1 of this form. It is your responsibility to forward the check promptly

to the recipient IRA or plan.

A. IRA Certiication

NAME OF IRA TRUSTEE (COMPANY NAME)

I certify by my signature on this form that the IRA identiied above will accept a direct rollover of my distribution and that the IRA is U.S.-based and is or is intended to be: an individual retirement account described in Internal Revenue Code (IRC) §408(a), an individual retirement annuity (other than an endowment contract) described in IRC §408(b), a Simpliied Employee Pension (SEP) account described in IRC §408(k) or a Roth IRA subject to the requirements established in IRC §408A(b).

For Roth IRAs only

I understand that the taxable portion of this rollover will be reported as taxable income in the year of distribution. UC will not automatically withhold for federal or state taxes on direct rollovers to Roth IRAs. My withholding preferences are indicated below:

Do not withhold federal or California (CA) state taxes on this rollover to a Roth IRA (default)

Withhold federal taxes on this rollover to a Roth IRA: a lat dollar amount: $________________ or a percentage: ___________%

Withhold CA state taxes on this rollover to a Roth IRA: a lat dollar amount: $________________ or a percentage: ___________%

Caution: Please consult your tax adviser. You may owe substantial federal and state taxes due to the rollover to a Roth IRA and you may be subject to an underwithholding penalty. Withholding income taxes from the amount transferred (instead of paying applicable income taxes from another source) may adversely impact the expected inancial beneits of rolling over to a Roth IRA and may result in an early distribution penalty tax (if applicable).

B. Qualiied Plan Certiication

NAME OF EMPLOYER

MAKE ROLLOVER CHECK PAYABLE TO TRUSTEE OF

I certify by my signature on this form that the employer plan identiied above is, or is intended to be, a qualiied deined contribution plan under IRC §401(a) or 401(k), or is described under IRC §403(b), or is a deferred compensation plan under IRC §457. I declare that the plan will accept a direct rollover from the University of California Retirement Plan, a deined beneit retirement plan under IRC §401(a).

5. REQUIRED SIGNATURE

I certify under penalty of perjury that:

•the information I have provided on this request is complete and true to the best of my knowledge,

•I have not concealed any relevant facts, and

•there are no claims against my UCRP/CAP beneits arising from a marriage/State-Registered Domestic Partnership during my UC employment.

The election made on this form will not be effective if the form is received by Retirement Administration after the member’s death.

I further certify that I have received and read UC’s Special Tax Notice for UC Retirement Plan Distributions and understand the tax consequences of my distribution request. My signature below certiies that I have separated from UC employment and am no longer on active UC pay status.

RETN: Pending

PRIVACY NOTIFICATIONS

STATE

The State of California Information Practices Act of 1977 (effective July 1, 1978) requires the University to provide the following information to individuals who are asked to supply information about themselves.

The principal purpose for requesting information on this form, including your Social Security number, is to verify your identity, and/or for beneits administra- tion, and/or for federal and state income tax reporting. University policy and state and federal statutes authorize the maintenance of this information.

Furnishing all information requested on this form is mandatory. Failure to provide such information will delay or may even prevent completion of the action for which the form is being illed out. Information furnished on this form may be transmitted to the federal and state governments when required by law.

Individuals have the right to review their own records in accordance with University personnel policy and collective bargaining agreements. Information on applicable policies and agreements can be obtained from campus or Office of the President Staff and Academic Personnel Offices.

The official responsible for maintaining the information contained on this form is the Vice President—University of California Human Resources, 1111 Franklin Street, Oakland, CA 94607-5200.

FEDERAL

Pursuant to the Federal Privacy Act of 1974, you are hereby notiied that disclosure of your Social Security number is mandatory. The University’s record keeping system was established prior to January 1, 1975 under the authority of The Regents of the University of California under Article IX, Section 9 of the California Constitution. The principal uses of your Social Security number shall be for state tax and federal income tax (under Internal Revenue Code sections 6011.6051 and 6059) reporting, and/or for beneits administration, and/or to verify your identity.