Transcription of Oregon Withholding Statement and Exemption Certificate
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Oregon Withholding Statement and Exemption Certificate
Submit this form to your employer 19612201010000 Oregon Department of Revenue2022 Form OR-W-4 Oregon Withholding Statement and Exemption CertificateOffice use onlyPage 1 of 1, 150-101-402 (Rev. 09-30-21, ver. 01) Employer s nameEmployee s signature (This form isn t valid unless signed.)Social Security number (SSN)Federal employer identification number (FEIN)DateAddressEmployer s addressCityCityStateStateZIP codeZIP codeNote: 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 Select one: Single Married Married, but Withholding at the higher single rate.
Oregon Withholding Statement and Exemption Certificate Office use only Page 1 of 1, 150-101-402 (Rev. 09-30-21, ver. 01) Employer’s name Employee’s signature (This form isn’t valid unless signed.) Social Security number (SSN) Federal employer identification number (FEIN) Date Address Employer’s address City City State State ZIP code ZIP ...
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