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For Oregon Purposes Only

Form W-4 (2011)

Complete all worksheets that apply. However,

Form 1040-ES, Estimated Tax for Individuals.

you may claim fewer (or zero) allowances. For

Otherwise, you may owe additional tax. If you

regular wages, withholding must be based on

have pension or annuity income, see Pub. 919 to

allowances you claimed and may not be a flat

find out if you should adjust your withholding on

Purpose. Complete Form W-4 so that your

amount or percentage of wages.

Form W-4 or W-4P.

employer can withhold the correct federal

income tax from your pay. Consider completing a

Head of household. Generally, you may claim

Two earners or multiple jobs. If you have a

new Form W-4 each year and when your

head of household filing status on your tax return

working spouse or more than one job, figure the

personal or financial situation changes.

only if you are unmarried and pay more than

total number of allowances you are entitled to

50% of the costs of keeping up a home for

claim on all jobs using worksheets from only one

Exemption from withholding. If you are exempt,

yourself and your dependent(s) or other

Form W-4. Your withholding usually will be most

complete only lines 1, 2, 3, 4, and 7 and sign

qualifying individuals. See Pub. 501, Exemptions,

accurate when all allowances are claimed on the

the form to validate it. Your exemption for 2011

Standard Deduction, and Filing Information, for

Form W-4 for the highest paying job and zero

expires February 16, 2012. See Pub. 505, Tax

information.

allowances are claimed on the others. See Pub.

Withholding and Estimated Tax.

919 for details.

Tax credits. You can take projected tax credits

Note. If another person can claim you as a

Nonresident alien. If you are a nonresident alien,

into account in figuring your allowable number of

dependent on his or her tax return, you cannot

withholding allowances. Credits for child or

see Notice 1392, Supplemental Form W-4

claim exemption from withholding if your income

dependent care expenses and the child tax

Instructions for Nonresident Aliens, before

exceeds $950 and includes more than $300 of

credit may be claimed using the Personal

completing this form.

unearned income (for example, interest and

Allowances Worksheet below. See Pub. 919,

dividends).

Check your withholding. After your Form W-4

How Do I Adjust My Tax Withholding, for

takes effect, use Pub. 919 to see how the

Basic instructions. If you are not exempt,

information on converting your other credits into

amount you are having withheld compares to

complete the Personal Allowances Worksheet

withholding allowances.

your projected total tax for 2011. See Pub. 919,

below. The worksheets on page 2 further adjust

Nonwage income. If you have a large amount of

especially if your earnings exceed $130,000

your withholding allowances based on itemized

nonwage income, such as interest or dividends,

(Single) or $180,000 (Married).

deductions, certain credits, adjustments to

consider making estimated tax payments using

income, or two-earners/multiple jobs situations.

Personal Allowances Worksheet (Keep for your records.)

Enter “1” for yourself if no one else can claim you as a dependent .

{

}

• You are single and have only one job; or

Enter “1” if:

• You are married, have only one job, and your spouse does not work; or

• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.

Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more

than one job. (Entering “-0-” may help you avoid having too little tax withheld.) .

Enter number of dependents (other than your spouse or yourself) you will claim on your tax return .

Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above)

Enter “1” if you have at least $1,900 of child or dependent care expenses for which you plan to claim a credit

(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)

Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.

• If your total income will be less than $61,000 ($90,000 if married), enter “2” for each eligible child; then less “1” if you have three or more eligible children.

• If your total income will be between $61,000 and $84,000 ($90,000 and $119,000 if married), enter “1” for each eligible

child plus “1” additional if you have six or more eligible children .

Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.)

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• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the

Deductions

For accuracy,

and Adjustments Worksheet

on page 2.

complete all

• If you have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed

worksheets

$40,000 ($10,000 if married), see the

Two-Earners/Multiple Jobs Worksheet

on page 2 to avoid having too little tax withheld.

that apply.

• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.

Cut here and give Form W-4 to your employer. Keep the top part for your records.

W-4

Employee's Withholding Allowance Certificate

OMB No. 1545-2159

2011

Form

Whether you are entitled to claim a certain number of allowances or exemption from withholding is

▶

Department of the Treasury

subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

Internal Revenue Service

Your social security number

Type or print your first name and middle initial.

Last name

Home address (number and street or rural route)

Single

Married

Married, but withhold at higher Single rate.

Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.

City or town, state, and ZIP code

4 If your last name differs from that shown on your social security card,

check here. You must call 1-800-772-1213 for a replacement card.

▶

Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)

Additional amount, if any, you want withheld from each paycheck

I claim exemption from withholding for 2011, and I certify that I meet both of the following conditions for exemption.

• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability and

• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.

If you meet both conditions, write “Exempt” here .

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Under penalties of perjury, I declare that I have examined this certificate and to the best of my knowledge and belief, it is true, correct, and complete.

Employee’s signature

Date

(This form is not valid unless you sign it.)

▶

Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)

9 Office code (optional)

Employer identification number (EIN)

W-4

For Privacy Act and Paperwork Reduction Act Notice, see page 2.

Form

(2011)

Cat. No. 10220Q