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—Submit your completed form to your employer— 19612601010000 Oregon Department of Revenue 2026 Form OR-W-4 Oregon Withholding Statement and Exemption Certificate Page 1 of 1, 150-101-402 (Rev. 07-28-25, ver. 01) Employer name Employee signature (This form isn’t valid unless signed.) Social Security number (SSN) Federal employer identification number (FEIN) Date Address Employer 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 withhold at the higher single rate. Note: Select “Single” if you’re married but legally separated or your spouse is a non-U.S. citizen without permanent resident status. 2. Allowances. Enter the number from Worksheet A, line A5, Worksheet B, line B9, or Worksheet C, line C6 (see instructions). Otherwise, if you aren’t exempt, enter 0 2. 3. Additional amount from Worksheet C, line C10, or other amount to withhold from each paycheck 3. 4. Exemption from withholding. I certify my wages are exempt from withholding and I meet the conditions for exemption as stated in Form OR-W-4 Instructions. Complete both lines: • Enter your exemption code from the Exemption chart in Form OR-W-4 Instructions 4a. • Write “Exempt” 4b. Sign here. Under penalty of false swearing, I declare the information provided is true, correct, and complete. Last name Initial Redetermination Employer use only. First name Office use only – – .00 Clear this page