Employee Request To Withhold Multnomah County Resident Income Tax
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1Employee Request to Withhold Multnomah County Resident Income Tax
EMPLOYEE INFORMATION
Employee Number:
Social Security Number:
Name:
FIRST
MI
LAST
RESIDENCE ADDRESS:
MAILING ADDRESS IF DIFFERENT:
NUMBER AND STREET
NUMBER AND STREET
CITY, STATE, ZIP
CITY, STATE, ZIP
COUNTY OF RESIDENCE
COUNTY
TAX INFORMATION
I authorize my employer to withhold County Income Tax from my wages.
1.
I authorize my employer to withhold County Income Taxes plus
2.
an additional $_____________ from my wages each period.
Please stop additional requested withholding.
3.
I do not wish my employer to withhold the tax at this time.
4.
I am a Multnomah County Resident and choose to make either
installments or a lump sum payment.
I am not a Multnomah County Resident.
Note: Only Multnomah County Residents Should Fill Out and Return to Payroll
PLEASE RETURN THIS FORM TO PAYROLL
SIGNATURE
DATE
Return to Payroll
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