EMPLOYEE’S WITHHOLDING CERTIFICATE FOR THE CITY OF PORTLAND INCOME TAX   
                PW-4 
Na   1. Print Full Name                                                   Social Security Number 
    
     2.  Address                                                          City                                       State Zip 
 
     Resident                Non Resident 
      
                                          3. Exemptions for yourself                                                            
    EMPLOYEE:  File this form with your 
    employer.  Otherwise, they must       4. Exemptions for your spouse                                                         
    withhold CITY OF PORTLAND income 
    tax from your earnings without        5. Exemptions for your children or other dependents                                   
    exemptions. 
     
    EMPLOYER:  Keep this certificate with 6.  Add the number of exemptions which you have claimed on                            
    your records.  If the information     lines 3, 4, and 5 above and write the total 
    submitted by the employee is not       
    believed to be true, correct and      7.  Enter a dollar amount for extra withholding 
    complete, the Administrator must be   I certify that the information submitted on this certificate is true, correct and complete to 
    so advised.                           the best of my knowledge and belief 
                                          Date Signature 

                                      EMPLOYEE’S WITHHOLDING CERTIFICATE FOR THE CITY OF PORTLAND INCOME TAX   
                PW-4 
Na   1. Print Full Name                                                   Social Security Number 
    
     2.  Address                                                          City                                       State Zip 
 
                                          Resident                                         Non Resident              
      
                                          3. Exemptions for yourself                                                            
    EMPLOYEE:  File this form with your 
    employer.  Otherwise, they must       4. Exemptions for your spouse                                                         
    withhold CITY OF PORTLAND income 
    tax from your earnings without        5. Exemptions for your children or other dependents                                   
    exemptions. 
     
    EMPLOYER:  Keep this certificate with 6.  Add the number of exemptions which you have claimed on                            
    your records.  If the information     lines 3, 4, and 5 above and write the total 
    submitted by the employee is not       
    believed to be true, correct and      7.  Enter a dollar amount for extra withholding 
    complete, the Administrator must be   I certify that the information submitted on this certificate is true, correct and complete to 
    so advised.                           the best of my knowledge and belief 
                                          Date Signature 

                                      EMPLOYEE’S WITHHOLDING CERTIFICATE FOR THE CITY OF PORTLAND INCOME TAX   
                PW-4 
Na   1. Print Full Name                                                   Social Security Number 
    
     2.  Address                                                          City                                       State Zip 
 
     Resident                                                Non Resident 
                                          3. Exemptions for yourself                                                            
    EMPLOYEE:  File this form with your 
    employer.  Otherwise, they must       4. Exemptions for your spouse                                                         
    withhold CITY OF PORTLAND income 
    tax from your earnings without        5. Exemptions for your children or other dependents                                   
    exemptions. 
     
    EMPLOYER:  Keep this certificate with 6.  Add the number of exemptions which you have claimed on                            
    your records.  If the information     lines 3, 4, and 5 above and write the total 
    submitted by the employee is not       
    believed to be true, correct and      7.  Enter a dollar amount for extra withholding 
    complete, the Administrator must be   I certify that the information submitted on this certificate is true, correct and complete to 
    so advised.                           the best of my knowledge and belief 
                                          Date Signature