OR-W-4

2020 Form OR-W-4 Page 1 of 4, 150-101-402 (Rev. 11-01-19, ver. 01) Oregon Withholding

First name*

Initial

Last name*

Social Security number (SSN)*

Note: Your eligibility to claim a certain number of allowances or an exemption from withholding may be subject to review by the Oregon Department of Revenue. Your employer may be required to send a copy of this form to the department for review.*

1.Married, but withholding at the higher single rate. Note: Check the "Single" box If you're married and you're legally separated or if your spouse Is a nonresident allen.MarriedSingle

Address*

Address

Street Address Line 2

CityState (CA, WA, UT, etc.)

ZIP code

2. Allowances. Total number of allowances you're claiming on line A4, B15, or C5. If you meet a qualification to skip the worksheets and you aren't exempt, enter 0 2.

3. Additional amount, If any, you want withheld from each paycheck 3.

4. Exemption from withholding. I certify that my wages are exempt from withholding and I meet the conditions for exemption as stated on page 2 of the instructions. Complete both lines below: Enter the corresponding exemption code. (See instructions) 4a. Write "Exempt" 4b.

Employee's signature (This form isn't valid unless signed.)*

Sign here. Under penalty of false swearing, I declare that the information provided is true, correct, and complete. Employee's signature (This form isn't valid unless signedDate

Date*

Date

Employer's name*

Employer Address

City

State

Zip Code

Address

Employer's address

Street Address Line 2

CityState

ZIP code