Employee’s Withholding Certificate for the City of Portland Income Tax                      PW-4           
1. Print Full Name                                                       Social Security Number 

2. Address                                                               City and State               Zip 

Resident    ⃝                   Non-Resident    ⃝                                                          
3. Exemptions for yourself                                                                                 
4. Exemptions for your spouse                                                                              
5. Exemptions for your children or other dependents                                                        
6. Add the number of exemptions which you have claimed on lines 3, 4, and 5 above and write the total      
7. Enter a dollar amount for extra withholding                                                            $ 
I certify that the information submitted on this certificate is true, correct, and complete to the best of my knowledge and belief. 
Date                       Signature 

EMPLOYEE: File this form with your employer. Otherwise, they must withhold City of Portland income tax from your earnings without exemptions 
if they are a required withholder.   EMPLOYER: Keep this certificate with your records. If the information submitted by the employee is not believed 
to be true, correct, and complete, the Administrator must be so advised.