CORRECTED (if checked)

PAYER’S name, street address, city or town, state or province, 1 Gross distribution OMB No. 1545-0119 Distributions From
country, ZIP or foreign postal code, and telephone no. Pensions, Annuities,
Retirement or
REGENTS OF THE UNIVERSITY OF CALIFORNIA
UC RETIREMENT SYSTEM
$ 28144.05
2a Taxable amount 2021 Profit-Sharing Plans,
IRAs, Insurance
1111 FRANKLIN STREET Contracts, etc.
OAKLAND, CA 94607-5201 $ 28144.05 Form 1099-R
2b Taxable amount Total Copy B
not determined distribution
Report this
PAYER’S TIN RECIPIENT’S TIN 3 Capital gain (included in 4 Federal income tax
income on your
box 2a) withheld
federal tax
return. If this
94-2557406 558-15-7363 $ $ 304.45 form shows
RECIPIENT’S name 5 Employee contributions/ 6 Net unrealized federal income
Designated Roth appreciation in tax withheld in
contributions or employer’s securities
DAVID ISAMU MIURA insurance premiums box 4, attach
$ $ this copy to
IRA/ your return.
Street address (including apt. no.) 7 Distribution 8 Other
code(s) SEP/
SIMPLE
1556 W KIMBERLY AVE This information is
7 $ %
being furnished to
City or town, state or province, country, and ZIP or foreign postal code 9a Your percentage of total 9b Total employee contributions the IRS.
ANAHEIM, CA 92802 distribution %$
10 Amount allocable to IRR 11 1st year of desig. 12 FATCA filing 14 State tax withheld 15 State/Payer’s state no. 16 State distribution
within 5 years Roth contrib. requirement
$ 0.00 CA/801-4215-1 $
$ $ $
Account number (see instructions) 13 Date of 17 Local tax withheld 18 Name of locality 19 Local distribution
payment $ $
AS 0016684 $ $
Form 1099-R www.irs.gov/Form1099R Department of the Treasury - Internal Revenue Service
Instructions for Recipient as periodic payments, nonperiodic payments, or a total distribution.
Generally, distributions from retirement plans (IRAs, qualified plans, Report the amount on Form 1040, 1040-SR, or 1040-NR on the line
section 403(b) plans, and governmental section 457(b) plans), for “IRA distributions” or "Pensions and annuities” (or the line for
insurance contracts, etc., are reported to recipients on Form 1099-R. “Taxable amount”) and on Form 8606, as applicable. However, if this
Qualified plans and section 403(b) plans. If your annuity starting is a lump-sum distribution, see Form 4972. If you haven’t reached
date is after 1997, you must use the simplified method to figure your minimum retirement age, report your disability payments on the line
taxable amount if your payer didn’t show the taxable amount in box for “Wages, salaries, tips, etc.” on your tax return. Also report on that
2a. See the instructions for your tax return. line permissible withdrawals from eligible automatic contribution
IRAs. For distributions from a traditional individual retirement arrangements and corrective distributions of excess deferrals, excess
arrangement (IRA), simplified employee pension (SEP), or savings contributions, or excess aggregate contributions except if the
incentive match plan for employees (SIMPLE), generally the payer isn’t distribution is of designated Roth contributions or your after-tax
required to compute the taxable amount. See the instructions for your contributions or if you’re self-employed.
tax return to determine the taxable amount. If you’re at least age 72, If a life insurance, annuity, qualified long-term care, or endowment
you must take minimum distributions from your IRA (other than a Roth contract was transferred tax free to another trustee or contract issuer,
IRA). If you don’t, you’re subject to a 50% excise tax on the amount an amount will be shown in this box and code 6 will be shown in box
that should’ve been distributed. See Pub. 590-A and Pub. 590-B for 7. If a charge or payment was made against the cash value of an
more information on IRAs. annuity contract or the cash surrender value of a life insurance
Roth IRAs. For distributions from a Roth IRA, generally the payer isn’t contract for the purchase of qualified long-term care insurance, an
required to compute the taxable amount. You must compute any amount will be shown in this box and code W will be shown in box 7.
taxable amount on Form 8606. An amount shown in box 2a may be You need not report these amounts on your tax return. If code C is
taxable earnings on an excess contribution. shown in box 7, the amount shown in box 1 is a receipt of reportable
Loans treated as distributions. If you borrow money from a qualified death benefits that is taxable in part.
plan, section 403(b) plan, or governmental section 457(b) plan, you may Box 2a. This part of the distribution is generally taxable. If there is no
have to treat the loan as a distribution and include all or part of the entry in this box, the payer may not have all the facts needed to figure
amount borrowed in your income. There are exceptions to this rule. If the taxable amount. In that case, the first box in box 2b should be
your loan is taxable, code L will be shown in box 7. See Pub. 575. checked. You may want to get one of the free publications from the IRS
Recipient’s taxpayer identification number (TIN). For your to help you figure the taxable amount. See Additional information on the
protection, this form may show only the last four digits of your TIN back of Copy 2. For an IRA distribution, see IRAs and Roth IRAs, earlier.
(SSN, ITIN, ATIN, or EIN). However, the payer has reported your For a direct rollover, other than from a qualified plan, section 403(b)
complete TIN to the IRS. plan, or governmental section 457(b) plan to a designated Roth account
Account number. May show an account, policy, or other unique in the same plan or to a Roth IRA, zero should be shown and you must
number the payer assigned to distinguish your account. enter zero (-0-) on the “Taxable amount” line of your tax return. If you
Box 1. Shows the total amount distributed this year. The amount may roll over a distribution (other than a distribution from a designated Roth
have been a direct rollover, a transfer or conversion to a Roth IRA, a account) from a qualified plan, section 403(b) plan, or governmental
recharacterized IRA contribution; or you may have received it section 457(b) plan to a designated Roth account in the same plan or to
(Continued on the back of Copy C)
 CORRECTED (if checked)
PAYER’S name, street address, city or town, state or province, 1 Gross distribution OMB No. 1545-0119 Distributions From
country, ZIP or foreign postal code, and telephone no. Pensions, Annuities,
Retirement or
REGENTS OF THE UNIVERSITY OF CALIFORNIA
UC RETIREMENT SYSTEM
$ 28144.05
2a Taxable amount 2021 Profit-Sharing Plans,
IRAs, Insurance
1111 FRANKLIN STREET Contracts, etc.
OAKLAND, CA 94607-5201 $ 28144.05 Form 1099-R
2b Taxable amount Total Copy C
not determined distribution
For Recipient’s
PAYER’S TIN RECIPIENT’S TIN 3 Capital gain (included in 4 Federal income tax
box 2a) withheld
Records

94-2557406 558-15-7363 $ $ 304.45

RECIPIENT’S name 5 Employee contributions/ 6 Net unrealized
Designated Roth appreciation in
contributions or employer’s securities
DAVID ISAMU MIURA insurance premiums
$ $
Street address (including apt. no.) 7 Distribution IRA/ 8 Other
code(s) SEP/
1556 W KIMBERLY AVE
SIMPLE This information is
7 $ % being furnished to
City or town, state or province, country, and ZIP or foreign postal code 9a Your percentage of total 9b Total employee contributions the IRS.
ANAHEIM, CA 92802 distribution %$
10 Amount allocable to IRR 11 1st year of desig. 12 FATCA filing 14 State tax withheld 15 State/Payer’s state no. 16 State distribution
within 5 years Roth contrib. requirement
$ 0.00 CA/801-4215-1 $
$ $ $
Account number (see instructions) 13 Date of 17 Local tax withheld 18 Name of locality 19 Local distribution
payment $ $
AS 0016684 $ $
Form 1099-R (keep for your records) www.irs.gov/Form1099R Department of the Treasury - Internal Revenue Service
Instructions for Recipient (continued) Box 6. If you received a lump-sum distribution from a qualified plan
a Roth IRA, you must include on the “Taxable amount” line of your tax that includes securities of the employer’s company, the net unrealized
return the amount shown in this box plus the amount in box 6, if any. appreciation (NUA) (any increase in value of such securities while in
If this is a total distribution from a qualified plan and you were born the trust) is taxed only when you sell the securities unless you choose
before January 2, 1936 (or you’re the beneficiary of someone born to include it in your gross income this year. See Pub. 575 and
before January 2, 1936), you may be eligible for the 10-year tax Form 4972. If you roll over the distribution to a designated Roth
option. See the Form 4972 instructions for more information. account in the same plan or to a Roth IRA, see the instructions for box
If you’re an eligible retired public safety officer who elected to 2a. For a direct rollover to a designated Roth account in the same plan
exclude from income distributions from your eligible plan used to pay or to a Roth IRA, the NUA is included in box 2a. If you didn’t receive a
certain insurance premiums, the amount shown in box 2a hasn’t been lump-sum distribution, the amount shown is the NUA attributable to
reduced by the exclusion amount. See the instructions for your tax employee contributions, which isn’t taxed until you sell the securities.
return for more information. Box 7. The following codes identify the distribution you received. For
Box 2b. If the first box is checked, the payer was unable to determine more information on these distributions, see the instructions for your
the taxable amount and box 2a should be blank, except for an IRA. tax return. Also, certain distributions may be subject to an additional
It’s your responsibility to determine the taxable amount. If the second 10% tax. See the Instructions for Form 5329.
box is checked, the distribution was a total distribution that closed out 1—Early distribution, no known exception (in most cases, under age
your account. 59½).
Box 3. If you received a lump-sum distribution from a qualified plan 2—Early distribution, exception applies (under age 59½).
and were born before January 2, 1936 (or you’re the beneficiary of 3—Disability.
someone born before January 2, 1936), you may be able to elect to 4—Death.
treat this amount as a capital gain on Form 4972 (not on Schedule D 5—Prohibited transaction.
(Form 1040)). See the Form 4972 instructions. For a charitable gift 6—Section 1035 exchange (a tax-free exchange of life insurance,
annuity, report as a long-term capital gain as explained in the annuity, qualified long-term care insurance, or endowment
Instructions for Form 8949. contracts).
Box 4. Shows federal income tax withheld. Include this amount on 7—Normal distribution.
your income tax return as tax withheld, and if box 4 shows an amount 8—Excess contributions plus earnings/excess deferrals (and/or
(other than zero), attach Copy B to your return. Generally, if you earnings) taxable in 2021.
receive payments that aren’t eligible rollover distributions, you can 9—Cost of current life insurance protection.
change your withholding or elect not to have income tax withheld by A—May be eligible for 10-year tax option (see Form 4972).
giving the payer Form W-4P. B—Designated Roth account distribution.
Box 5. Generally, this shows the employee’s investment in the Note: If code B is in box 7 and an amount is reported in box 11,
contract (after-tax contributions), if any, recovered tax free this year; see the Instructions for Form 5329.
the portion that’s your basis in a designated Roth account; the part of C—Reportable death benefits under section 6050Y.
premiums paid on commercial annuities or insurance contracts D—Annuity payments from nonqualified annuities that may be subject
recovered tax free; the nontaxable part of a charitable gift annuity; or to tax under section 1411.
the investment in a life insurance contract reportable under section
E—Distributions under Employee Plans Compliance Resolution
6050Y. This box doesn’t show any IRA contributions. If the amount
System (EPCRS).
shown is your basis in a designated Roth account, the year you first
(Continued on the back of Copy 2)
made contributions to that account may be entered in box 11.
 CORRECTED (if checked)
PAYER’S name, street address, city or town, state or province, 1 Gross distribution OMB No. 1545-0119 Distributions From
country, ZIP or foreign postal code, and telephone no. Pensions, Annuities,
Retirement or
REGENTS OF THE UNIVERSITY OF CALIFORNIA
UC RETIREMENT SYSTEM
$ 28144.05
2a Taxable amount 2021 Profit-Sharing Plans,
IRAs, Insurance
1111 FRANKLIN STREET Contracts, etc.
OAKLAND, CA 94607-5201 $ 28144.05 Form 1099-R
2b Taxable amount Total Copy 2
not determined distribution
File this copy
PAYER’S TIN RECIPIENT’S TIN 3 Capital gain (included in 4 Federal income tax
with your state,
box 2a) withheld
city, or local
income tax
94-2557406 558-15-7363 $ $ 304.45 return, when
RECIPIENT’S name 5 Employee contributions/ 6 Net unrealized required.
Designated Roth appreciation in
contributions or employer’s securities
DAVID ISAMU MIURA insurance premiums
$ $
Street address (including apt. no.) 7 Distribution IRA/ 8 Other
code(s) SEP/
SIMPLE
1556 W KIMBERLY AVE
7 $ %
City or town, state or province, country, and ZIP or foreign postal code 9a Your percentage of total 9b Total employee contributions
ANAHEIM, CA 92802 distribution %$
10 Amount allocable to IRR 11 1st year of desig. 12 FATCA filing 14 State tax withheld 15 State/Payer’s state no. 16 State distribution
within 5 years Roth contrib. requirement
$ 0.00 CA/801-4215-1 $
$ $ $
Account number (see instructions) 13 Date of 17 Local tax withheld 18 Name of locality 19 Local distribution
payment $ $
AS 0016684 $ $
Form 1099-R www.irs.gov/Form1099R Department of the Treasury - Internal Revenue Service
Instructions for Recipient (continued) were made for qualified long-term care insurance contracts under
F—Charitable gift annuity. combined arrangements, the amount of the reduction in the
G—Direct rollover of a distribution to a qualified plan, a section 403(b) investment (but not below zero) in the annuity or life insurance
plan, a governmental section 457(b) plan, or an IRA. contract is reported here.
H—Direct rollover of a designated Roth account distribution to a Roth Box 9a. If a total distribution was made to more than one person, the
IRA. percentage you received is shown.
J—Early distribution from a Roth IRA, no known exception (in most Box 9b. For a life annuity from a qualified plan or from a section
cases, under age 59½). 403(b) plan (with after-tax contributions), an amount may be shown for
K—Distribution of traditional IRA assets not having a readily available the employee’s total investment in the contract. It is used to compute
FMV. the taxable part of the distribution. See Pub. 575.
L—Loans treated as distributions. Box 10. If an amount is reported in this box, see the Instructions for
M—Qualified plan loan offset. Form 5329 and Pub. 575.
N—Recharacterized IRA contribution made for 2021 and Box 11. The first year you made a contribution to the designated Roth
recharacterized in 2021. account reported on this form is shown in this box.
P—Excess contributions plus earnings/excess deferrals (and/or Box 12. If checked, the payer is reporting on this Form 1099 to satisfy
earnings) taxable in 2020. its Internal Revenue Code chapter 4 account reporting requirement
Q—Qualified distribution from a Roth IRA. under FATCA. You may also have a filing requirement. See the
R—Recharacterized IRA contribution made for 2020 and Instructions for Form 8938.
recharacterized in 2021. Box 13. Shows the date of payment for reportable death benefits
S—Early distribution from a SIMPLE IRA in first 2 years, no known under section 6050Y.
exception (under age 59½). Boxes 14–19. If state or local income tax was withheld from the
T—Roth IRA distribution, exception applies. distribution, boxes 16 and 19 may show the part of the distribution
U—Dividend distribution from ESOP under section 404(k). subject to state and/or local tax.
Note: This distribution isn’t eligible for rollover. Additional information. You may want to see:
W—Charges or payments for purchasing qualified long-term care Form W-4P, Form 4972, Form 5329, Form 8606
insurance contracts under combined arrangements.
Pub. 525, Taxable and Nontaxable Income
If the IRA/SEP/SIMPLE box is checked, you’ve received a traditional Pub. 560, Retirement Plans for Small Business
IRA, SEP, or SIMPLE distribution.
Pub. 571, Tax-Sheltered Annuity Plans
Box 8. If you received an annuity contract as part of a distribution, the
Pub. 575, Pension and Annuity Income
value of the contract is shown. It isn’t taxable when you receive it and
Pub. 590-A, Contributions to IRAs
shouldn’t be included in boxes 1 and 2a. When you receive periodic
payments from the annuity contract, they’re taxable at that time. If the Pub. 590-B, Distributions from IRAs
distribution is made to more than one person, the percentage of the Pub. 721, U.S. Civil Service Retirement Benefits
annuity contract distributed to you is also shown. You’ll need this Pub. 939, General Rule for Pensions and Annuities
information if you use the 10-year tax option (Form 4972). If charges Pub. 969, HSAs and Other Tax-Favored Health Plans