Part A - Oregon

1 Form W-4P (2018) 2018 Form W-4 PDepartment of the Treasury Internal Revenue Service Form W-4 PPart BOregon State Tax Withholding Certificatefor pension or Annuity PaymentsFor Privacy Act and Paperwork Reduction Act Notice, see page No. 1545-007420182018 Your first name and middle initialLast nameYour Social Security numberHome address (number and street or rural route)Claim or identification number (if any) of your pension or annuity contract (optional)City or town, state, and ZIP codeComplete the following applicable check here if you do not want any state income tax withheld from your pension or annuity. (Do not complete lines 2 or 3.)

2 2 Total number of allowances and marital status you are claiming for withholding from each periodic pension or annuity payment. (You also may designate an additional dollar amount on line 3.).. Marital status: Single Married Married, but withhold at a higher single Additional amount, if any, you want withheld from each pension or annuity payment. (Note: For periodic payments, you cannot enter an amount here without entering the number (including zero) of allowances on line 2.) .. The amount you enter on line 3 will be deducted in addition to the amount deducted based on the marital status and allowance entered on line signature Date $_____ Contact the Oregon Department of Revenue in Salem at 503-378-4988 or for questions regarding Oregon state ce Use Only Member Alternate Payee Cross-Reference Member SSNForm W-4 PPart AFederal Tax Withholding Certificatefor pension or Annuity PaymentsFor Privacy Act and Paperwork Reduction Act Notice, see page No.

3 1545-0074202018 Your first name and middle initialLast nameYour Social Security numberHome address (number and street or rural route)Claim or identification number (if any) of your pension or annuity contract (optional)City or town, state, and ZIP codeComplete the following applicable check here if you do not want any federal income tax withheld from your pension or annuity. (Do not complete lines 2 or 3.) ..2 Total number of allowances and marital status you are claiming for withholding from each periodic pension or annuity payment. (You also may designate an additional dollar amount on line 3.).. Marital status: Single Married Married, but withhold at a higher single Additional amount, if any, you want withheld from each pension or annuity payment.

4 (Note: For periodic payments,. you cannot enter an amount here without entering the number (including zero) of allowances on line 2.) .. The amount you enter on line 3 will be deducted in addition to the amount deducted based on the marital status and allowances entered on line signature Date $_____ (Enter number of allowances.)_____(Enter number of allowances.)_____Oregon state tax withholding will be based on Section A unless you complete Section B. Retirees who are not Oregon residents who do not want Oregon tax withheld should check the box on Line 1 in Section and sign this form.

5 Form W-4P is not valid unless you sign and date each part of the form you complete. Incomplete forms will be returned. Mail to: PERS, PO Box 23700, Tigard, OR 97281-3700 or fax to developments. For the latest information about any future de-velopments related to Form W-4P, such as legislation enacted after it was published, go to Form W-4P is for citizens, resident aliens, or their estates who are recipients of pensions, annuities (including commercial annuities), and certain other deferred compensation. Use Form W-4P to tell payers the correct amount of federal income tax to withhold from your payment(s). You also may use Form W-4P to choose (a) not to have any federal income tax withheld from the payment (except for eligible rollover distributions or for payments to citizens to be delivered outside the United States or its possessions) or (b) to have an additional amount of tax withheld.

6 Your options depend on whether the payment is periodic, nonperiodic, or an eligible rollover distribution, as explained on pages 2 and 3. Your previous-ly fi led Form W-4P will remain in effect if you don t fi le a Form W-4P for No. 10225T1. Is this a new withholding or a change to an existing withholding? (Select one.) New withholding (Complete Parts A and B) Change to existing withholding2. Are you an Oregon resident? (Select one.) Ye s No (Complete Part B, line 1 if you want no Oregon tax withheld.)3. Account type (Select all that apply for this withholding). To indicate different withholdings for each account, complete a separate form W-4P for each account. OPSRP IAP installments of 10 years or longer OPSRP Alternate payee OPSRP Benefi ciary OPSRP Disability If you receive periodic payments and you complete line 3 of the form, you must complete line 2, including the number of allowances.

7 The amount you enter on line 3 will be deducted in addition to the amount deducted based on the marital status and allowances entered on line 2. Refer to IRS Publication 505, Tax Withholding and Estimated Tax, if you need further W-4P (2018) Cat. No. 10225 TPage 2 of 3 Personal Allowances WorksheetEnter 1 for yourself .. Enter 1 if you will fi le as married fi ling jointly ..Enter 1 if you will fi le as head of household .. Enter 1 if: .. You re single, or married fi ling separately, and have only one pension ; or You re married fi ling jointly, have only one pension , and your spouse has no income subject to withholding; or Your income from a second pension or a job or your spouse s pension or wages (or the total of all) are $1,500 or less.

8 Child tax credit. See Pub. 972, Child Tax Credit, for more information. If your total income will be less than $69,801 ($101,401 if married fi ling jointly), enter 4 for each eligible child. If your total income will be from $69,801 to $175,550 ($101,401 to $339,000 if married fi ling jointly), enter 2 for each eligible child. If your total income will be from $175,551 to $200,000 ($339,001 to $400,000 if married fi ling jointly), enter 1 for each eligible child. If your total income will be higher than $200,000 ($400,000 if married fi ling jointly), enter -0- ..Credit for other dependents. If your total income will be less than $69,801 ($101,401 if married fi ling jointly), enter 1 for each eligible dependent.

9 If your total income will be from $69,801 to $175,550 ($101,401 to $339,000 if married fi ling jointly), enter 1 for every two dependents (for example, -0- for one dependent, 1 if you have two or three dependents, and 2 if you have four dependents). If your total income will be higher than $175,550 ($339,000 if married fi ling jointly), enter -0- ..Other credits. If you have other credits, see Worksheet 1-6 of Pub. 505 and enter the amount from that worksheet here ..Add line A through G and enter the total here ..ABCDEFGHABCDEFGHFor accuracy, complete all worksheets that and Adjustments WorksheetNote: Use this worksheet only if you plan to itemize deductions, claim certain adjustments to income, or have a large amount of other an estimate of your 2018 itemized deductions.

10 These include qualifying home mortgage interest, charitable con-tributions, state and local taxes (up to $10,000), and medical expenses in excess of your income. See Pub. 505 for details ..Enter: $24,000 if you re married fi ling jointly or qualifying widow(er) $18,000 if you re head of household $12,000 if you re single or married fi ling separately ..Subtract line 2 from line 1. If zero or less, enter -0- ..Enter an estimate of your 2018 adjustments to income and any additional standard deduction for age or blindness (see Pub. 505 for information about these items) ..Add lines 3 and 4 and enter the total ..Enter an estimate of your 2018 other income (such as dividends, interest, or capital gains).