—Provide this form to your employer—
19612001010000
Oregon Department of Revenue
2020 Form OR-W-4
Oregon Withholding
Office use only
Page 1 of 4, 150-101-402
(Rev. 11-01-19, ver. 01)
Employer’s name
Employee’s signature (This form isn’t valid unless signed.)
Social Security number (SSN)
Federal employer identication number (FEIN)
Date
Separate here and give Form OR-W-4 to your employer. Keep the worksheets for your records.
Oregon Employee’s Withholding Statement and Exemption Certificate
Form OR-W-4 2020
Address
Employer’s address
City
City
State
State
ZIP code
ZIP code
Note: 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 review.
1. Select one: Single Married Married, but withholding at the higher single rate.
Note: Check the “Single” box if you’re married and you’re legally separated or if your spouse is a nonresident alien.
2. Allowances. Total number of allowances you’re claiming on line A4, B15, or C5. If you meet a
qualification to skip the worksheets and you aren’t exempt, enter -0- ...................................................2.
3. Additional amount, if any, you want withheld from each paycheck ...................................................... 3.
4. Exemption from withholding. I certify that my wages are exempt from withholding and I meet
the conditions for exemption as stated on page 2 of the instructions. Complete both lines below:
• Enter the corresponding exemption code. (See instructions) ........................................................... 4a.
• Write “Exempt” ................................................................................................................................... 4b.________________________
Sign here. Under penalty of false swearing, I declare that the information provided is true, correct, and complete.
Important information
Complete Form OR-W-4 if:
• You filed a federal Form W-4 with your employer after
December 31, 2017 and you didn’t file Form OR-W-4 or
specify a different number of allowances for Oregon.
• You weren’t satisfied with your prior year Oregon tax-to-
pay or refund amount.
• You’ve had a recent personal or financial change that may
affect your tax situation, such as a change in your income,
filing status, or number of dependents.
Specific information to consider:
• Do you (including your spouse) have more than one job?
• Do you expect your wages or adjusted gross income
(AGI) on your 2020 return to be more than $100,000 (or
$200,000 if filing using the married filing jointly or quali-
fied widow(er) filing status)?
• Are you making mid-year changes to your withholding?
• Do you receive pension or annuity payments?
• Are you a part-year resident, nonresident, or nonresident alien?
If you answered yes to any of these questions, read
the “Specific information” section in the instructions
before filling out the corresponding worksheets or
Form OR-W-4. The online Oregon Withholding Calculator
at www.oregon.gov/dor may provide more accurate results.
If you use the online calculator, you don’t need to complete
the corresponding worksheets.
Otherwise, read the instructions and complete all applicable
worksheets before filling out the Form OR-W-4 and giving
it to your employer.
STOP
First name Last nameInitial Redetermination
Employer use only.
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MASTERY LEARNING INSTITUTE - ARTHUR ACADEMY
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13809 SE DIVISION PORTLAND OR 97236
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