Oregon Employee’s Withholding Statement and Exemption Certificate

 Employee’s Withholding Statement and Exemption Certificate
2023 Form OR-W-4, Oregon withholding, 150-101-402
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2023 Form OR-W-4
Page 1 of 1, 150-101-402
(Rev. 09-15-22, ver. 01)

Office use only

19612301010000

Oregon Department of Revenue

Oregon Withholding Statement and Exemption Certificate

First name

Initial Last name

Redetermination

Social Security number (SSN)

–
Address

–

City

State

ZIP code

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.

2.

Select one:	
Single	
Married	
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 alien.
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.

.00

3.		Additional amount, if any, you want withheld from each paycheck....................................................... 3.
4.

Exemption from withholding. I certify 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.________________________

Sign here. Under penalty of false swearing, I declare the information provided is true, correct, and complete.
Date

Employee signature (This form isn’t valid unless signed.)

Employer use only.
Employer name

Federal employer identification number (FEIN)

Employer address

City

­—Submit this form to your employer—

State

ZIP code