OR – Horizons Portal

Download W4 Instructions
Note: Your eligibility to claim a certain number of allowances or an exemption from withholding is 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: If married, but legally separated, or if your spouse is a nonresident alien, check the “Single” box.
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-
3. Additional amount, if any, you want withheld from each paycheck

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.
Write “Exempt"

Under penalties of perjury, I certify that I have examined this certificate and to the best of my knowledge and belief, it is true, correct, and complete.*
- I certify the above statement
Social Security Number*
Employee Signature – Type Your Name*
Today's Date*
My IP Address is: 44.192.115.114
This form was submitted on: 09/21/2023

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