—Provide this form to your employer—
Oregon Department of Revenue
2021 Form OR-W-4
Oregon Employee’s Withholding Statement and Exemption Certificate
Office use only
Page 1 of 1, 150-101-402
(Rev. 08-14-20, ver. 01)
Employer’s name
Employee’s signature (This form isn’t valid unless signed.)
Social Security number (SSN)
Federal employer identication number (FEIN)
Date
Address
Employer’s address
City
City
State
State
ZIP code
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. 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.
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.________________________
Sign here. Under penalty of false swearing, I declare that the information provided is true, correct, and complete.
First name Last nameInitial Redetermination
Employer use only.
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