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.

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

Employer's name

Employer Address

City

State

Zip Code

Address

Employer's address

Street Address Line 2

CityState

ZIP code