- 1 -
|
1 1
1 2 2 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 Form With grid With grid & data2 84 85
3 4 82 83
3 3
4 4
5 2024 Form OR-W-4 Office use only 5
6 Page 1 of 1, 150-101-402 Oregon Department of Revenue 19612401010000 6
7 (Rev. 08-18-23, ver. 01) 7
8 Oregon Withholding Statement and Exemption Certificate 8
9 9
10 10
11 11
12 12
13 First name Initial Last name Social Security number (SSN) Redetermination 13
X
14 XXXXXXXXXXXX X XXXXXXXXXXXXXXXXXXXX999-99-9999– – 14
15 Address City State ZIP code 15
16 16
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX
17 Note: Your eligibility to claim a certain number of allowances or an exemption from withholding may be subject to review by the 17
18 Oregon Department of Revenue. Your employer may be required to send a copy of this form to the department for review. 18
19 19
20 1. Select one: X Single X Married X Married, but withhold at the higher single rate. 20
21 Note: Select “Single” if you’re married but legally separated or your spouse is a non-U.S. citizen without permanent resident status. 21
22 22
23 2. Allowances. Total number of allowances you’re claiming on lineA4, B15, orC5. 23
24 See worksheets in the instructions. If you skip the worksheets and aren’t exempt, enter 0 ............. 2. 99 24
25 25
26 3. Additional amount, if any, you want withheld from each paycheck ...................................................... 3. 999,999,999.00.00 26
27 27
28 4. Exemption from withholding. I certify my wages are exempt from withholding and I meet 28
29 the conditions for exemption as stated on page 2 of the instructions. Complete both lines below: 29
30 • Enter your exemption code. (See instructions) ................................................................................. 4a. 9 30
31 • Write “Exempt” ...................................................................................................................................4b.________________________XXXXXX 31
32 32
33 Sign here. Under penalty of false swearing, I declare the information provided is true, correct, and complete. 33
34 Employee signature (This form isn’t valid unless signed.) Date 34
35 35
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 99/99/9999
36 Employer use only. 36
37 Employer name Federal employer identification number (FEIN) 37
38 38
39 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXEmployer address 99-9999999City State ZIP code 39
40 40
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX
41 41
42 42
43 —Submit this form to your employer— 43
44 44
45 45
46 46
47 47
48 48
49 49
50 50
51 51
52 52
53 53
54 54
55 55
56 56
57 57
58 58
59 59
60 60
61 61
62 62
63 63
64 64
1 2 65 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 65 84 85
3 4 82 83
66 66
|