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5 2023 Form OR-W-4 Office use only 5
6 Page 1 of 1, 150-101-402 Oregon Department of Revenue 19612301010000 6
7 (Rev. 09-15-22, ver. 01) 7
8 Oregon Withholding Statement and Exemption Certificate 8
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13 First name Initial Last name Social Security number (SSN) Redetermination 13
X
14 XXXXXXXXXXXX X XXXXXXXXXXXXXXXXXXXX999-99-9999– – 14
15 Address City State ZIP code 15
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX
17 Note: Your eligibility to claim a certain number of allowances or an exemption from withholding may be subject to review by the 17
18 Oregon Department of Revenue. Your employer may be required to send a copy of this form to the department for review. 18
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20 1. Select one: X Single X Married X Married, but withholding at the higher single rate. 20
21 Note: Check the “Single” box if you’re married and you’re legally separated or if your spouse is a nonresident alien. 21
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23 2. Allowances. Total number of allowances you’re claiming on lineA4, B15, orC5. If you meet a 23
24 qualification to skip the worksheets and you aren’t exempt, enter 0 .....................................................2. 99 24
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26 3. Additional amount, if any, you want withheld from each paycheck ...................................................... 3. 999,999,999.00.00 26
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28 4. Exemption from withholding. I certify my wages are exempt from withholding and I meet 28
29 the conditions for exemption as stated on page 2 of the instructions. Complete both lines below: 29
30 • Enter the corresponding exemption code. (See instructions) ........................................................... 4a. 9 30
31 • Write “Exempt” ...................................................................................................................................4b.________________________XXXXXX 31
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33 Sign here. Under penalty of false swearing, I declare the information provided is true, correct, and complete. 33
34 Employee signature (This form isn’t valid unless signed.) Date 34
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 99/99/9999
36 Employer use only. 36
37 Employer name Federal employer identification number (FEIN) 37
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39 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXEmployer address 99-9999999City State ZIP code 39
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX
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43 —Submit this form to your employer— 43
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