Instructions for form #459-364 (3/6/2024) Page 1 of 12
Instructions for Tier One/Tier Two and Individual Account Program
(IAP) Retirement Application
You will receive your rst Tier One/Tier Two Program benet payment within 92 days of your eective
retirement date. Your IAP benet payment is normally paid within 120 days.
11410 SW 68th Parkway, Tigard OR 97223
Mailing Address – PO Box 23700, Tigard OR
97281-3700
General retirement information
General information on lling out the application
• You can either ll out this application online or ll out a hard copy. If you choose a hard copy, please print clearly
with dark ink. Both online and hard copy methods require member hand sign and date in signature and notary areas.
• Your signature, and your spouse’s signature if married, must be notarized on page two of the application. PERS
sta can notarize applications at a Retirement Application Assistance Session (RAAS).
• Do not cross out, modify, or alter the application in any way—this could void your application.
• Please provide your personal email address. Conrmation and follow up letters are sent via email whenever possible.
• Depending on your choices, you may need to complete additional forms. For example, if you choose a direct
deposit for your installments, you must complete the Authorization Agreement for Automatic Deposits form. We
have provided links to the additional forms where appropriate. Contact PERS Member Services if you are reading
a paper version of these instructions and need additional support.
• Generally, you have the right to change your option, beneciary designation, or, if applicable, variable
participation, within the rst 60 days after the issue date of the rst benet payment. Changes are retroactive to
your eective retirement date. For specic limitations, see “Section A Part 1: Your Guide to Retirement Options”
of the Tier One/Tier Two and Individual Account Program (IAP) Pre-Retirement Guide.
• PERS must know your exact date of birth to calculate your retirement benet. If you choose a survivorship option,
PERS must also validate your beneciary’s date of birth. You will nd a list of acceptable verication of age
documents on page 3.
• Please use your full legal name to complete and sign forms. If submitting a driver’s license or passport as your age
verication document, your name on the application and age verication document should match. If your legal
name is not reected on your driver’s license or passport, complete the application using your current legal name
and provide proof of legal name change (marriage certicate, court document, etc.).
• You must be eligible to retire. Visit the Benefit Component Comparison page on PERS website.
• You must separate from employment with all PERS-participating employers before your eective retirement date.
• If your account is divorce-related, retirement option and beneciary restrictions may apply.
• Your application is not eective until PERS accepts it. PERS will mail or email you a letter conrming receipt of
your application and may request additional items required for application acceptance.
• When you retire from Tier One/Tier Two, you must also retire from the IAP. Complete this application to retire
from both programs.
• If you have a Tier One/Tier Two Loss of Membership (LOM) account, consider applying for it now to avoid
retirement benet processing delays. To apply for the LOM account payout, complete either the
Loss of Membership Refund Application or a Tier One/Tier Two Member Account Withdrawal Application and
submit it before or with your retirement application.
Instructions for form #459-364 (3/6/2024) Page 2 of 12
• PERS must receive payment for waiting time, refunded time, and other purchases of service time credit before your
eective date of retirement. Some special, full-cost purchases, may be made after your eective retirement date.
• The tax forms you will need to complete may be impacted by your elections so please pay close attention to
which tax forms you are including with your application.
• Include your name and Social Security number (SSN) or PERS ID at the top of every page and on any documents
submitted with your application. Providing your SSN is mandatory, and PERS is authorized to request it under
Internal Revenue code provisions. It will be used primarily to comply with mandatory IRS reporting. However,
PERS may also use it internally for conrmation purposes or recovery of overpaid funds. (If you do not want it
used for these purposes, enclose a written statement to that eect with your retirement application.)
• Registered domestic partners, see the Tier One/Tier Two and Individual Account Program (IAP) PreRetirement
Guide for more information.
• Mail, fax, or deliver your completed application with accompanying forms and required documents to PERS.
Keep a copy for your records.
Forms and documents needed to receive benets
• Tier One/Tier Two/Individual Account Program (IAP) Retirement Application.
• Verication of your age.
• Verication of your beneciary’s age (required if you select a survivorship option).
o (Survivorship Options: 2, 2A, 3, 3A, Lump Sum (LS) Option 2, LS2A, LS3, LS3A).
• Verication of legal name change if your current legal name diers from the name on le with PERS.
• Authorization Agreement for Automatic Deposit form (if you are electing to receive benet via direct deposit).
• W-4P form for federal and state tax withholding if you select a monthly Tier One/Tier Two option or IAP
installments of 10 years or longer.
o (Tier One/Tier Two: All options are monthly or include a monthly except Total Lump Sum).
o (IAP: Installments for 10 years, 15 years, 20 years, or the Anticipated Life Span Option).
• W-4R Tier One/Tier Two Lump Sum Withholding form if you select any Tier One/Tier Two Lump Sum (LS)
option and are not requesting a 100% rollover.
o (Options: Total Lump Sum, Lump Sum (LS) Option 1, LS2, LS2A, LS3, LS3A).
This form is also needed if you have Police and Firefighter (P&F) Units and are not requesting a 100% rollover
if you are age 65 or older, or if when your P&F unit balance is calculated, it results in an amount that exceeds $4,000.
• W-4R IAP Lump Sum Withholding form if you select IAP One-time lump sum or a 5 year installment and are
not requesting a 100% rollover.
• Tier One/Tier Two Direct Transfer Rollover Acceptance form if you select a lump sum benet and elect to roll all
or a portion of your benet to another deferred compensation or eligible employer plan,
• IAP Direct Transfer Rollover Acceptance form if you select IAP One-time lump sum or a 5 year installment and
elect to roll all or a portion of your benet to another deferred compensation or eligible employer plan.
(3/28/2022)
Acceptable documentation to verify date of birth
Photocopies of birth-date documents and, if applicable, beneciary birth-date documents are required before
benets are paid. We will not accept documents that are incomplete, appear to be altered, or are dicult to
read. If your documents are not accepted, you will need to submit new photocopies. Please include your PERS
ID or Social Security number on all documents submitted, including beneciary documents.
If it is impossible for you to furnish the proof required in Group 1 or 2, write to PERS with a full explanation.
Since the documents submitted cannot be returned, we suggest using photocopies. If it is illegal to copy a
document, bring it in, and PERS will verify the birth information.
Be sure to put the PERS member’s Social Security number on all documents so they are properly recorded.
**A compliant REAL ID will have a picture of a star, or a star cutout in the upper right-hand corner of the card. In lieu of REAL IDs, some states also have issued
“enhanced” driver’s licenses, driver’s permits, or ID cards. Enhanced cards are REAL ID compliant and will bear an American ag emblem and the word “enhanced”
on the front of the card.
Group 1
If one item in this group is furnished showing birth dates, no
further evidence of age is needed.
Any ONE of these:
Group 2
Two items in this group from different sources are sufficient if
age or birth date is shown.
Any TWO of these:
Example: One child’s birth certificate and one driver’s license
• Copy of Oregon driver’s license or ID card if issued on or
after February 4, 2008 (current or expired).
• Copy of REAL ID driver’s license, driver’s permit, or ID
card issued by any state** (current or expired).
• Birth verification issued by state, county, or country
(documents issued by foreign governments in a language
other than English need to include a translation into
English certified by a notary public, public agency, or
other public official).
• American Indian Reservation Age Verification.
• Infant baptism certificate.
• Hospital birth certificate (if signed by attending.
physician or issued by state).
• Passport (current or expired).
• School-age record.
• Naturalization or citizenship papers.
• Family Bible record (if this record is furnished, include the
following information certified by a notary public or other
public official: copy of all family record entries in the Bible
referring to applicant and parents, brothers, and sisters;
Bible publication date or apparent age of Bible; when birth
date was entered and by whom).
• A notarized affidavit by an older, immediate family
member in a position to know the birth date (e.g., father,
mother, etc.)
• Certificate of military record
• Marriage record (record must show your age or date of
birth at time of marriage)
• Any other state’s driver’s license or ID card. (must be
current)
• County voter registration (must show your age or date of
birth; do not send in your precinct card)
• Copy of child’s birth certificate if it shows age of parents
• Social Security record (record must be displayed on
an estimate of benefits or screen print from the Social
Security office; document must be dated within
last 12 months)
• Military ID (military record DD214)
• Concealed weapons permit
Page 3 of 12
Instructions for form #459-364 (3/6/2024) Page 4 of 12
PERS must know your citizenship for tax purposes. Check the appropriate box.
• Check I am a U.S. citizen or resident noncitizen if you are a U.S. citizen or a resident noncitizen.
— If you are a United States citizen living outside of the United States, you will be required to complete
form W-9 and are not allowed to claim exempt from United States federal income tax withholding. The
W-9 is available in the Forms section of the PERS website.
• Check I am a nonresident noncitizen if you are a nonresident noncitizen and complete IRS form W-8BEN:
Certicate of Foreign Status of Benecial Owner for United States Tax Withholding. This form is available in the
Forms section of the PERS website.
Section C: U.S. Citizenship (required)
Section A: Applicant Information (required)
Step-by-step instructions for lling out your retirement application
Section D: Residency (required)
Fill in this section completely.
Provide your Social Security number (SSN) and your PERS ID. If you do not know your PERS ID, leave the PERS ID box
blank; however, providing your SSN is mandatory. Your application will be delayed if SSN is missing.
Enter your date of birth in the area provided. You must also present document(s) to verify your age. You will nd a list of
acceptable verication of age documents on page 3 of these instructions.
Provide your personal email address. Conrmation and follow up letters are sent via email whenever possible.
Section B: Eective retirement date (required)
Enter the month and year you want your retirement to begin. Retirements always begin on the rst of the month, so you only
need to enter the month and year.
Your eective retirement date can be no sooner than either the rst day of the month following the last day you worked
(or were on qualifying paid leave) or the rst of the month following the month PERS receives your retirement application,
whichever is later. Examples: If your last day worked is May 5, 2022, your retirement date can be no earlier than June
1, 2022. If your last day worked was May 5, 2022, but PERS does not receive your application until June 6, 2022, your
retirement date can be no earlier than July 1, 2022.
Please note the following restrictions:
• To change or establish a new retirement date, you must submit a new retirement application and any additional
required forms. PERS must receive these, as required by law, before the issue date of your rst benet payment.
• To cancel your retirement application, PERS must receive a written and signed cancellation request before the
issue date of your rst benet payment. This request can be faxed to 503-598-0561, mailed to P.O. Box 23700,
Tigard, OR 97281-3700, or delivered to PERS at 11410 SW 68th Parkway, Tigard, OR 97223.
You may be eligible for an additional benet called “Tax Remedy.” Eligibility for this benet is tied to dates and length of
service, and residency. When calculating your benet, PERS will determine if you are eligible to receive the Tax
Remedy benet.
Check the appropriate box and sign in this section to indicate whether you are an Oregon resident and subject to
Oregon personal income tax or not. PERS will not use your mailing address to determine residency.
Instructions for form #459-364 (3/6/2024) Page 5 of 12
By signing Section G you are acknowledging that you have read and understand the limitations of working for a
PERS-participating employer after retirement. Unsigned forms could delay processing your benets.
Work After Retirement Information for Tier One/Tier Two Retirees
If you return to employment with a PERS-participating employer in the state of Oregon after retirement, Oregon statutes
impose certain limitations on that employment. Compliance with the statutory limitations is your responsibility. If you
exceed the work-hour limitations, you will be accountable. Exceeding the limitations may lead to your retirement benets
being canceled and you being invoiced for any overpaid benets.
Notice: Senate Bill 1049, passed by the Oregon Legislature in 2019, lifted most restrictions on working after retirement for
calendar years 2020 through 2024. As a result of House Bill 2296, passed by the Oregon Legislature in 2023, these rules
will now continue through December 31, 2034. During these years, most PERS retirees who retire at “normal” retirement
age may return to work for a PERS-participating employer and still collect their PERS retirement benets with no limitations
imposed by PERS. Your employer may have other limitations on your work hours.
Find full information on the PERS website, including owcharts, to see if you can work unlimited hours while continuing to
receive your pension benet.
Early retiree PERS Work-After-Retirement limitations
If you retire early, follow these guidelines to continue to receive your PERS benets if you go back to work for one or more
public employer(s) in Oregon:
• Make sure you have a complete break from any PERS-participating employment for at least six full months after your
retirement date, before returning to work, if you want to work unlimited hours.
• If you do not have a six-month break, as a Tier One or Tier Two early retiree, you may work less than 1,040 hours in a
calendar year as a retiree, unless you qualify for a special exception. Learn more and see exceptions to this rule on the
PERS website.
Social Security limitations
If you are receiving Social Security benets and have not reached “full retirement age” (FRA) under Social Security, the
Social Security Administration and PERS have additional limitations on your employment. If you have not reached FRA, you
may need to limit your hours to stay within the income allowed under the annual Social Security income limits. For details,
go to the Social Security website.
Section E: Working after retirement acknowledgement (required)
The IRS requires PERS to notify you of the tax consequences of taking a distribution by providing the Federal Tax
Information Disclosure.
By signing Section G you are acknowledging that you have received and read the Federal Tax Information Disclosure.
You have 30 days to review your distribution options and the associated tax consequences. PERS will not process your
payment until the 30-day period has passed unless you check the box to waive your right to this 30-day period. If you
check the waiver box, PERS will process your distribution as soon as possible.
If PERS is unable to process your distribution within 180 days from the signature date in Section G, the IRS requires us to
provide the Federal Tax Information Disclosure again, and you will need to complete a new Acknowledgement of Receipt
of Federal Tax Information Disclosure form. We will contact you if this happens.
Section F: Acknowledgement of Receipt of Federal Tax Information Disclosure (required)
Section G: Member signature (required)
You must sign and date in Section G to acknowledge the statements in Sections E and F and declare the information you
have provided on this page is true to the best of your knowledge and belief.
Section H: Retirement options (required)
Important: We highly recommend you read and understand “Part One: Your Guide to Retirement Options” of the Tier One/
Tier Two and Individual Account Program (IAP) Pre-Retirement Guide before lling out this section. You cannot change
options after 60 days from the issue date of your rst regular benet payment.
Any corrections, alterations, or omissions in this section may require a new application be submitted which could cause a
delay processing your benets.
Instructions for form #459-364 (3/6/2024) Page 6 of 12
Please note – the retirement options have been numbered #1 - #13 to assist you in determining which subsequent
sections are relevant to the option you selected. Please do not confuse the #1 - #13 numbering with the ‘name of the
option’ which may also include a number.
Select only ONE of the 13 options listed.
To select a Non-survivorship Option put a check in the box next to the non-survivorship option you have chosen
and complete the beneciary designation in Section K. Do not complete the ‘Survivorship option beneciary ONLY’
box located in Section H.
To select a Survivorship Option put a check in the box next to the survivorship option you have chosen and complete
the ‘Survivorship option beneciary ONLY’ box located in Section H.
• You may only name one beneciary and it must be a person. The beneciary will receive both a continuing
monthly benet and, if you selected a lump-sum option, any unpaid lump-sum installments.
• You must provide your beneciary’s legal name, date of birth, and the beneciary’s relationship to you. Your
application will be returned if information is missing. This could delay your benet.
• PERS also requests that you provide your beneciary’s Social Security number. This can be an important tool in
identifying and locating your beneciary after your passing.
You can only choose one benet option. If more than one box is checked, we must return the application to you. This
could delay your benet.
Aggregate Sum (AS) Refund information – Some members may receive an estimate or letter stating their monthly Tier
One/Tier Two benet will be less than $200 a month and they will receive an AS Refund. Although an AS Refund may be
paid in lieu of a monthly pension benet, the AS Refund is not a selectable benet option. All retiring members must choose
a valid option in Section H.
Section I: Verication of Age (required)
Check the boxes to indicate you are submitting age documentation for yourself and for your beneciary (if you selected a
survivorship option).
A list of acceptable verication of age documents is on page 3 of these instructions. Illegible verication of age documents
routinely cause benet delays. Please provide legible documentation.
Section J: Member declaration and Spousal consent - notarized signatures (required)
Do not complete any part of this section until you are with the notary. Any corrections, alterations, or omissions in this
section may require a new application to be submitted which could cause a delay processing your benets. Notary stamp
must be legible.
Member:
• You must select one of the marital status boxes to indicate your marital status as of your eective retirement date.
• Your signature and date must be notarized.
• Your signature date and the notary’s signature date must be the same date.
Member’s Spouse (if member is married):
• Your signature and date must be notarized to indicate your spousal consent of the option and beneficiary
selected by the member.
• Your signature date and the notary’s signature date must be the same date.
Failure of a married member to obtain valid spousal consent in this section will result in a mandatory default to Option 3
with your spouse as your beneciary.
Section H: Retirement options (required)
Instructions for form #459-364 (3/6/2024) Page 7 of 12
ONLY complete this section if you chose a non-survivorship option (Box # 1 – 5 in Section H): Option 1, Refund
Annuity, 15-Year Certain, Lump-Sum Option 1, or Total Lump-Sum.
• If you selected Option 1 or Refund Annuity and die on or after your eective retirement date, but before your rst
payment is due, your death will be considered a pre-retirement death. In this event, PERS will use the beneciary
on this application as your pre-retirement designation.
Check the appropriate box to use the standard beneciary designation or to name specic beneciaries.
If you choose the standard designation, do not name any specic person. Instead, your beneciary selection follows the
order described in law.
The standard designation directs PERS to pay benets in the order listed below:
1) Your spouse, if legally married at the time of death. If not married, then to
2) Your child* or children in equal shares. If any of your children are deceased, their portion is equally divided
between their children who are alive at the time of your death. If all of your children predecease you, the
benet will be awarded to your grandchildren living at the time of your death, in equal shares. If no children
or grandchildren survive you, then to
3) Your mother and father in equal shares, or to the survivor. If neither survives you, then to
4) Your brothers and sisters in equal shares, and the share of any brother or sister who does not survive you, to
their children living at the time of your death in equal shares. If none of your brothers or sisters survive you,
to the children of your brothers and sisters living at the time of your death in equal shares. If neither your
siblings nor their children survive you, then to
5) Your estate.
*Natural born and adopted children are considered “children” even if you selected the standard designation before or
after their adoption or birth. If your children are adopted by someone else, they are not considered your “children”
under the standard designation. If you wish to name the adopted-out children as your beneciary, use the specic
designation part of this form.
The specic designation allows you to name specic persons, charities, trusts, or your estate.
Providing requested information assists in locating your beneciary.
If you need to add more beneciaries, attach an additional sheet of paper that includes all the same information listed in
the table for each beneciary. Include your name and SSN at the top of each additional sheet.
• The percentages assigned to primary beneciaries must total 100%.
• If you do not assign percentages, the beneciaries on that level (primaries or alternates under each specic
primary) will share equally.
• You can name one or more alternate beneciaries for each of your primary beneciaries. The alternates will
receive the primary beneciary’s share if the primary beneciary predeceases you. Note: The percentage you
designate for the alternates must equal the percentage you assigned to the primary beneciary. (E.g., if you
designate 50% to primary beneciary #1 and have two alternates for that beneciary, the percentages for the two
alternates must total 50%.)
• If you name your estate as a beneciary, you may not provide an alternate beneciary for your estate.
Section K: Non-survivorship option beneciary designation
Instructions for form #459-364 (3/6/2024) Page 8 of 12
You must sign and date Section K. The beneciary designation is not valid unless signed. Your signature is required for
both the Standard and Specic designations.
Section L: Tier One/Tier Two lump-sum distribution installments
ONLY complete this section if you selected a lump-sum option. (Box # 4, 5, 10, 11, 12, or 13 in Section H)
Indicate whether you want to receive your lump-sum balance in one, two, three, four, or ve annual installments, and then
enter the amounts that correspond with the number of years you want to receive the balance.
You must allocate the percentages for each payment of your lump-sum balance.
Percentages do not have to be the same. For example, you can choose 50% the rst year, 25% the next year, 15% the
following year, and 10% the fourth year. How much you receive each year is up to you. The minimum installment is 1%.
Make sure the gures you enter are whole numbers and total 100%. If they do not, we will return your application to you.
This could delay your benet.
Section K: Non-survivorship option beneciary designation (continued)
The percentages of #1 and #2 primary beneciaries add up to 100% (50+50=100)
The percentages of #1a and #1b alternate beneciaries add up to the #1 primary’s (30+20=50)
The percentages of #2a and #2b alternate beneciaries add up to the #2 primary’s percentage (25+25=50)
Instructions for form #459-364 (3/6/2024) Page 9 of 12
Section M: Tier One/Tier Two lump-sum payment distribution
ONLY complete this section if you selected a lump-sum option. (Box # 4, 5, 10, 11, 12, or 13 in Section H)
Indicate whether or not to roll over any portion of your lump-sum distribution into a traditional IRA, Roth IRA, or another
deferred compensation or eligible employer plan.
Check box 1 if you want your lump-sum distribution to go directly to you. Please ll out the Direct Deposit form to
have your distribution deposited into your bank account. You will be taxed on your distribution, complete the W-4R Tier
One/Tier Two Lump Sum Withholding form. Selecting box 1 completes Section M.
Check box 2 to roll over your lump-sum distribution.
Fill in the information in 2a to indicate the specic percentage or dollar amount to be rolled over. If you roll over
less than 100% of your benet complete the W-4R Tier One/Tier Two Lump Sum Withholding form.
Fill in the information in 2b and 2c.
● Check one of the boxes under 2b to indicate whether the distribution(s) will be going to the Oregon Savings
Growth Plan (OSGP), a traditional IRA, Roth IRA, or another deferred compensation or eligible employer plan.
● In box 2c:
o Provide the name and contact information of your nancial institution or employer plan for your rollover
payment.
o The rollover check will be made payable to the institution or plan you provide in this box. If you are
uncertain to whom the check should be payable, please consult with your nancial institution/employer
plan prior to completing this section.
o Verify the address you provide is correct. The rollover payment will be mailed directly to this address.
o It is very important to provide your rollover account number for your funds to be correctly
deposited to your account. Contact your nancial institution for your account number. If your
nancial institution is unable to provide you an account number, complete this eld with the last four digits
of your social security number.
Note: If you are rolling over funds to another deferred compensation or employer plan other than OSGP, you must have
an authorized representative of the plan complete the Tier One/Tier Two Direct Transfer Rollover Acceptance form.
You must be a current OSGP participant to roll over your installment(s) to OSGP.
Section N: Variable election
ONLY complete this section if you have a Tier One/Tier Two Variable Account in addition to your Regular Account. A
Variable Account will be identied as such under the Tier One/Tier Two section of your Member Annual Statement.
Check the appropriate box to state whether or not you want to discontinue participation in the Variable Annuity at retirement.
If you continue participation in the Variable, the variable portion of your monthly retirement benet will increase or
decrease annually as the result of gains or losses from investments of the variable annuity account portfolio. You may change
your variable annuity election any time between your original election and within 60 days after the issue date of your rst
actual benet payment. After 60 days, you cannot change your variable annuity election.
If you elect a lump-sum option, your Variable Account will be automatically transferred out of the Variable and into your
Regular Account at retirement.
Instructions for form #459-364 (3/6/2024) Page 10 of 12
Section O: Police ocer and reghter (P&F) units
ONLY complete this section if you are or were a police ocer or reghter who has participated in or recently
made a purchase of P&F Units.
#1 - Select the correct box to indicate whether you will be 65 or older on your eective retirement date.
For those 65 or older, your units must be paid at retirement in a single lump payment. If this applies to you select one
of the payment options.
• If you select a direct payment, you will receive a check or direct deposit. You will be taxed on your distribution,
complete the W-4R Tier One/Tier Two Lump Sum Withholding form. This completes Section O.
• If you select a rollover, complete the Rollover-Eligible Distribution form. If you roll over less than 100% of your
benet complete the W-4R Tier One/Tier Two Lump Sum Withholding form. This completes Section O.
#2 – If under 65 on your eective retirement date, select box for your requested Units Benet Eective Date and
number of months units are to be paid.
• P&F unit benet payments are required to be made over a minimum of 5 years (60 months) unless payments
begin after the age of 60.
• All P&F unit benets must be paid in full by age 65.
• If P&F unit benet payments begin after the age of 60, the number of required monthly benets can be calculated
by subtracting the Unit Benet Eective date from the rst of the month following the member’s 65th birthday, or
from the member’s 65th birthday if the birthday falls on the 1st.
• P&F unit benet payments made for more than 5 years (60 months) are actuarially reduced.
#3 – If you selected in #2 to receive your unit benet eective on your retirement date in Section B:
When your unit benet is calculated if the balance exceeds $4,000, you will receive any amount above $4,000
as a single lump payment called P&F Excess. If the P&F Excess is $200 or more, the payment is eligible to be
rolled over into an IRA or other deferred compensation or eligible employer plan. PERS requests direction now to
avoid payment delays.
Select a box to indicate if P&F Excess should be paid as a direct payment or as a rollover.
• If you select a direct payment, you will receive a check or direct deposit. You will be taxed on your distribution,
complete the W-4R Tier One/Tier Two Lump Sum Withholding form.
• If you select a rollover, complete the Rollover-Eligible Distribution form. If you roll over less than 100% of your
benet complete the W-4R Tier One/Tier Two Lump Sum Withholding form.
Instructions for form #459-364 (3/6/2024) Page 11 of 12
The remaining sections apply only to your Individual Account Program (IAP) benet.
You should have an IAP if you worked for a PERS-participating employer in 2004 or
after.
Section P: IAP distribution option
You must choose one option in Section P to select your IAP distribution.
Be aware that all IAP distributions except those automatically deposited to your bank account and those rolled over to the
Oregon Savings Growth Plan (OSGP) will be mailed directly to the address listed in Section A of your application. In the
case of a rollover, your nancial institution will be the payee on the check. Requests for rollovers to the Oregon Savings
Growth Plan (OSGP) are automatically transferred from your IAP account into your OSGP account. You must be a current
OSGP participant to roll over your installment(s) to OSGP.
Distribution option details:
● One-time lump-sum distribution or 5-year installment distribution (rollover eligible)
In a one-time lump-sum distribution of your entire IAP account, or in the case of the 5-year installment
distribution, you may elect to have all or a portion of the distribution rolled over. These rollover-eligible
distributions can be paid directly to you or rolled over to an IRA, eligible employer plan, or deferred
compensation plan. It can also be split as a combination payment, including an amount rolled over, and the
remainder issued in a payment directly to you. The minimum pre-distribution account balance required for the
rollover portion in a combination split/roll distribution is $500.
If you choose a one-time lump-sum distribution or a 5-year installment distribution, you must also complete
Section Q. And you must also ll out the W-4R – IAP Lump Sum Withholding form if you are not rolling over
100% of your distribution.
● 10-, 15-, 20-year, and Anticipated Life-Span Option installment distribution
The 10-, 15-, 20-year, and Anticipated Life-Span Option installment distribution options are not rollover eligible.
You may choose to receive installment payments by a direct deposit into your bank account or by a check mailed
directly to you. You must also ll out the W-4P tax withholding form.
Frequency details for installment distribution options:
● 5-, 10-, 15-, 20-year, and Anticipated Life-Span Option installment distribution
All options other than the one-time lump-sum distribution receive installment payments. Because you will receive
installments you must also choose a monthly, quarterly, or annual distribution frequency.
Select your preferred frequency directly below your elected installment distribution.
Once your distribution has begun, your payment will be equal to the current market value of your account divided by the
number of payments left for the balance of the distribution. Because the market uctuates daily, each distribution may
be dierent based on the current market value of your account. If your account reaches a zero balance, your distribution
stops, regardless of the number of payments left for the option chosen.
If you elect an installment option, you must designate a beneciary by completing Section R.
If you decide you no longer wish to receive an installment distribution, you can make a one-time decision to cash out your
IAP account. Once the account is distributed as a cash-out, it is not reversible and will close your PERS IAP account.
Membership in PERS is retained with an IAP cash-out at retirement; should you return to qualifying employment, you will
not need to serve a six-month waiting period.
If you decide to cash out and the distribution of your remaining account balance is greater than $200, the distribution is
rollover-eligible and will be taxed accordingly.
If you decide to cash out, are under the age of 59½, and are not rolling over these funds, the IRS may assess a
10% early withdrawal penalty.
If you have any questions regarding tax laws, you may want to consult with a qualied tax professional or the IRS.
Instructions for form #459-364 (3/6/2024) Page 12 of 12
Section Q: IAP payment distribution
Section R: IAP beneciary designation
All members with an IAP should complete this section to designate a beneciary or beneciaries for the IAP. The
designation becomes eective on your eective retirement date. This designation applies if you select a one-time lump
sum and die on or after your eective retirement date but before your benet is distributed or if you select an installment
option and die anytime on or after your eective retirement date.
Check the appropriate box to use the standard beneciary designation or to name specic beneciaries.
Please refer to the instructions in Section K for information on Standard and Specic designations.
You must sign and date Section R. The beneciary designation is not valid unless signed. Your signature is required for
both the Standard and Specic designations.
ONLY complete this section if you selected one-time lump-sum or a 5-year installment. (Box # 1 or #2 in Section P)
Indicate whether or not to roll over any portion of your distribution into a traditional IRA, Roth IRA, or another deferred
compensation or eligible employer plan.
Check box 1 if you want your IAP distribution to go directly to you. Please ll out the Direct Deposit form to have
your distribution deposited into your bank account. You will be taxed on your distribution, complete the W-4R IAP Lump
Sum Withholding form. Selecting box 1 completes Section Q.
Check box 2 to roll over your IAP distribution.
Fill in the information in 2a to indicate the specic percentage or dollar amount to be rolled over. If you rollover
less than 100% of your benet, complete the W-4R IAP Lump Sum Withholding form.
Fill in the information in 2b and 2c.
● Check one of the boxes under 2b to indicate whether the distribution(s) will be going to the Oregon Savings Growth
Plan (OSGP), a traditional IRA, Roth IRA, or another deferred compensation or eligible employer plan.
● In box 2c, provide the name of your nancial institution or employer plan for your rollover payment. The rollover
check will be made payable to the institution or plan you provide in this box. If you are uncertain to whom the check
should be payable, please consult with your nancial institution or employer plan prior to completing this section.
Note: All IAP rollover checks other than to OSGP will be mailed to you with the nancial institution or employer plan as the
payee. You must be a current OSGP participant to roll over your distribution(s) to OSGP.
If you are rolling over funds to another deferred compensation or employer plan other than OSGP, you must have an
authorized representative of the plan complete the IAP Direct Transfer Rollover Acceptance form.
Section A: Applicant information
11410 SW 68th Parkway, Tigard OR 97223
Mailing Address – PO Box 23700, Tigard OR 97281-3700
Toll free – 888-320-7377 fax – 503-598-0561
Website – http://oregon.gov/pers
Section B: Eective retirement date
Tier One/Tier Two/Individual Account Program (IAP) Retirement Application
*Providing your Social Security number (SSN) is mandatory, and PERS is authorized to request it under provisions of the Internal Revenue code. It will primarily be used to
comply with mandatory IRS reporting. It could also be used for conrmation purposes or recovery of overpaid funds
.
In compliance with the Americans with Disabilities Act, PERS will provide help filling out this form upon request. You may request help by calling 888-320-7377 or TTY 503-603-7766.
My PERS retirement date is the rst day of:
PERS must receive your application
before this month and year.
_______________________ _____________________
Month Year
Section C: U.S. Citizenship (You are required to select one box below)
Section D: Residency (Required for Tax Remedy benet for those who are eligible)
q I am a U.S. citizen or resident noncitizen.
q I am a nonresident noncitizen, and I have completed and included my IRS W-8BEN form.
Applicant’s signature (Required for Section D – Residency) Date
Section F: Acknowledgement of Receipt of Federal Tax Information Disclosure
Section G: Member signature (Required)
Section E: Working after retirement acknowledgement
By signing in Section G, I acknowledge that I have received and read the PERS document entitled Working After
Retirement Information for Tier One/Tier Two Retirees.
By signing in Section G, I acknowledge that I have received and read the Federal Tax Information Disclosure.
q I waive my right to the 30-day period for reviewing the Federal Tax Information Disclosure. (optional)
I hereby declare that all statements on this page are true to the best of my knowledge and belief.
Applicant’s signature (Required for benet processing) Date
First name MI Last name PERS ID (optional)
Mailing address (street or PO box) Country Social Security number (Required)*
City State ZIP code Date of birth (mm/dd/yyyy)
Home phone number Work phone number Cell phone number Personal email
I hereby declare that the above statement is true to the best of my knowledge and belief, and I understand it is subject to
penalty for perjury.
Select one:
q I am a resident of the state of Oregon; therefore, payments made to me as a result of this benet application
will be subject to Oregon personal income tax.
q I am not a resident of the state of Oregon; therefore, payments made to me as a result of this benet application
will not be subject to Oregon personal income tax.
Form #459-364 (3/6/2024) SL3 IIM Code: 2163
Page 1 of 7
First name (required) MI Last name (required) Social Security number (required)
Do not complete any portion of this section until you are with the notary.
Member and spouse (if married) must sign in the presence of a notary.
Member declaration of marital status (Required)
Spousal consent (Required if married)
By my notarized signature below, I consent to the
option and beneciary my spouse selected.
Applicant’s signature Date Spouse’s signature Date
Notary Public Notary Public
State of County of State of County of
Applicant name Spouse name
Signed before me on this date Signed before me on this date
By (notary’s signature) By (notary’s signature)
NO ALTERATIONS OR CORRECTIONS ARE ALLOWED ON THIS PAGE
Section H: Retirement options (Required - Select only ONE of the 13 options below)
Non-Survivorship Options:
1.
q Option 1
2.
q Refund Annuity
3.
q 15-Year Certain
4.
q Lump-Sum Option 1
5.
q Total Lump-Sum
Survivorship Options:
6.
q Option 2
7.
q Option 2A
8.
q Option 3
9.
q Option 3A
10.
q Lump-Sum Option 2
11.
q Lump-Sum Option 2A
12.
q Lump-Sum Option 3
13.
q Lump-Sum Option 3A
You must name your beneciary(ies) in Section K.
Do NOT name a beneciary in the below Survivorship option beneciary area.
Survivorship option beneciary ONLY
Beneciary name (Required)
Beneciary date of birth - mm/dd/yyyy (Required)
Beneciary Social Security number (Requested)
Relationship to you (Required)
You must
name your
beneciary here.
You may only name
one person.
Do NOT complete
Section K
Section I: Verication of Age (Required) – see instructions for acceptable documentation
Section J: Member declaration and Spousal consent – notarized signatures (Required)
q I am submitting acceptable verication of age to PERS with my retirement application to verify my date of birth.
q I selected a survivorship option (6-13 above) and am submitting my beneciary’s verication of age to PERS.
q
As of my eective retirement date, I am married.
q
As of my eective retirement date, I am single.
Form #459-364 (3/6/2024) SL3 IIM Code: 2163
Page 2 of 7
First name (required) MI Last name (required) Social Security number (required)
Section K: Non-survivorship option beneciary designation
This Section is not for all members
ONLY complete this section if you chose a non-survivorship option (Box # 1 – 5 in Section H):
Option 1, Refund Annuity, 15-Year Certain, Lump-Sum Option 1, or Total Lump-Sum
Select only one Standard or Specic:
q STANDARD - I elect to use the Standard beneciary designation. Do not complete table below.
q SPECIFIC - I elect to use the Specic beneciary designation. Complete the table below.
Applicant’s signature (Required for Section K – Non-survivorship beneciary designation)
Date
q Check this box if you want PERS to apply the following: If any of the named primary beneciaries predecease
me and I have not named an alternate beneciary, I want the portion of my benet that was designated to that
beneciary shared equally among the remaining primary beneciaries living at my death.
I understand these beneciary designations become eective on my retirement date. (See instructions for details.)
Specic Primary beneciary #1 If living; otherwise, to #1 alternate beneciary(ies).
#1
Full name Social Security # Date of birth Phone Percentage
q Person
q C h a r i t y
q Estate
q Trust
Email or address Relationship
Alternate beneciary(ies) for Primary #1 Alternate percentages must equal percentage assigned to primary #1
#1a
Full name Social Security # Date of birth Phone Percentage
q Person
q C h a r i t y
q Estate
q Trust
Email or address Relationship
#1b
Full name Social Security # Date of birth Phone Percentage
q Person
q C h a r i t y
q Estate
q Trust
Email or address Relationship
Specic Primary beneciary #2 If living; otherwise, to #2 alternate beneciary(ies).
#2
Full name Social Security # Date of birth Phone Percentage
q Person
q C h a r i t y
q Estate
q Trust
Email or address Relationship
Alternate beneciary(ies) for Primary #2 Alternate percentages must equal percentage assigned to primary #2
#2a
Full name Social Security # Date of birth Phone Percentage
q Person
q C h a r i t y
q Estate
q Trust
Email or address Relationship
#2b
Full name Social Security # Date of birth Phone Percentage
q Person
q C h a r i t y
q Estate
q Trust
Email or address Relationship
Form #459-364 (3/6/2024) SL3 IIM Code: 2163
Page 3 of 7
q100% q Two installments: q Three installments: q Four installments: q Five installments:
1st
% 1st % 1st % 1st %
2nd
% 2nd % 2nd % 2nd %
% 3rd % 3rd % 3rd %
% 4th % 4th %
% 5th %
%
Section M: Tier One/Tier Two lump-sum payment distribution
W-4R Tier One/Tier Two Lump Sum Withholding form. Continue to next section.
2. q Roll over my distribution(s).
Subsections 2a, 2b, and 2c must be completed. Complete one line only under each 2a and 2b.
2a. Roll over _________________ % of my distribution, or
Roll over $ ____________ of my distribution.
2b. Roll to:
q Traditional IRA.
q Roth IRA.
q Oregon Savings Growth Plan (OSGP).
You must be a current OSGP participant to roll over your installment(s) to OSGP.
q Another deferred compensation or employer plan.
You must have an authorized representative of the plan complete the Tier One/Tier Two Direct
Transfer Rollover Acceptance form and submit it with your application if you check this box.
2c. Provide all requested information for your nancial institution or employer plan for your rollover below.
First name (required) MI Last name (required) Social Security number (required)
Section L: Tier One/Tier Two lump-sum distribution installments
This Section is not for all members
ONLY complete this section if you chose a lump-sum option
(Box # 4, 5, 10, 11, 12, or 13 in Section H)
Total Lump-Sum, Lump-Sum Option 1, Lump-Sum Option 2, Lump-Sum Option 2A, Lump-Sum Option 3, or Lump-Sum Option 3A
You can receive your lump-sum in one, two, three, four, or ve annual payments. Check the appropriate box below to
indicate how many installments you want to receive, and then enter the percentage you want for each installment. The
minimum installment is 1%. The total must equal 100%. (Select only one.)
This Section is not for all members
ON
LY complete this section if you chose a lump-sum option
(Box # 4, 5, 10, 11, 12, or 13 in Section H)
Total Lump-Sum, Lump-Sum Option 1, Lump-Sum Option 2, Lump-Sum Option 2A, Lump-Sum Option 3, or Lump-Sum Option 3A
1. q Do not roll over. Send distribution(s) directly to me, or direct deposit to my bank account. Complete the
Rollover check will be made payable to (nancial institution or employer plan name):
Address City State ZIP code
Account number (Required. See instructions) Contact person Phone number
Note: Rollover checks will be made payable based on the information you provide above and mailed directly to the nancial
institution/employer plan. Please verify complete, clear, accurate information is provided.
Form #459-364 (3/6/2024) SL3 IIM Code: 2163
Page 4 of 7
First name (required) MI Last name (required) Social Security number (required)
Section N: Variable election
This Section is not for all members
ONLY complete this section if you have a Tier One/Tier Two Variable Account in addition to your Regular Account.
(A variable account will be identied as such under the Tier One/Tier Two section of your Member Annual statement)
Do you want to discontinue participation in the Variable Annuity at retirement? (Select one below)
q Yes.
q No. I understand by remaining in the Variable Annuity this will cause my benet to increase or decrease.
1. Will you be 65 or older on your eective retirement date requested in Section B? (Select one below)
q Yes. You will receive your units at retirement as a single lump payment. (Select one below to complete Section O)
q Send my lump units payment directly to me, or direct deposit to my bank account. (Complete the
W-4R Tier One/Tier Two Lump Sum Withholding form.)
q I want to rollover my lump units payment. (Complete the Rollover-Eligible Distribution form.
In Section B of the Rollover-Eligible Distribution form, check the box labeled “P&F Excess Dollars”.
Submit the form with your retirement application.)
q No. Please continue to complete the remainder of Section O.
2. I would like my police ocer and reghter units benet eective: (Select one below)
q On my selected retirement date in Section B to be paid over ________ months. Complete #3 below.
Number
q Delayed until _______________1, _______ to be paid over ________ months. Do not complete #3 below.
Month Year Number
3. If you elected to receive your units based on the retirement date in Section B and your unit account balance on that
date exceeds $4,000.00, you will receive any amount above $4,000.00 as a single lump payment called P&F Excess.
If your P&F Excess payment is $200 or more, the payment will be eligible to be rolled over into an IRA or other
deferred compensation or eligible employer plan.
If, when my P&F unit balance is calculated, it results in an amount that is rollover eligible: (Select one below)
q
Send my P&F Excess payment directly to me, or direct deposit to my bank account. (Complete the W-4R Tier
One/Tier Two Lump Sum Withholding form.)
q
I want to rollover my P&F Excess payment. (Complete the Rollover-Eligible Distribution form.
In Section B of the Rollover-Eligible Distribution form, check the box labeled “P&F Excess Dollars”. Submit
the form with your retirement application.)
Section O: Police ocer and reghter units
This Section is not for all members
ONLY complete this section if you are or were a police ocer or reghter
who has participated in or recently made a purchase of P&F Units
Form #459-364 (3/6/2024) SL3 IIM Code: 2163
Page 5 of 7
First name (required) MI Last name (required) Social Security number (required)
Section P: IAP distribution option
(For most members who worked for a PERS-participating employer in 2004 or after)
Section Q: IAP payment distribution
Rollover check should be made payable to:
Note: All IAP rollover checks other than to the OSGP will be mailed to you with the nancial institution as the payee.
If you have an IAP account, select only one from the six choices below and follow the instructions based on your
selection. If you do not have an IAP account, Sections P, Q, and R do not apply to you.
1.
q One-time lump-sum distribution (rollover eligible). Complete Section Q.
Fill out the W-4R – IAP Lump Sum Withholding form if you are not rolling over 100 % of your distribution.
--------------------------------------------------------------------------------------------------------------
2.
q 5-year installment distribution (rollover eligible).
Select frequency:
q
Monthly
q
Quarterly
q
Annually Complete Section Q.
Fill out the W-4R – IAP Lump Sum Withholding form if you are not rolling over 100 % of your distribution.
--------------------------------------------------------------------------------------------------------------
3.
q 10-year installment distribution – (not rollover eligible). Fill out a W-4P tax withholding form.
Select frequency:
q
Monthly
q
Quarterly
q
Annually Skip Section Q.
--------------------------------------------------------------------------------------------------------------
4.
q 15-year installment distribution – (not rollover eligible). Fill out a W-4P tax withholding form.
Select frequency:
q
Monthly
q
Quarterly
q
Annually Skip Section Q.
--------------------------------------------------------------------------------------------------------------
5.
q 20-year installment distribution – (not rollover eligible). Fill out a W-4P tax withholding form.
Select frequency:
q
Monthly
q
Quarterly
q
Annually Skip Section Q.
--------------------------------------------------------------------------------------------------------------
6.
q Anticipated Life-Span Option installments – (not rollover eligible). Fill out a W-4P tax withholding form.
Select frequency:
q
Monthly
q
Quarterly
q
Annually Skip Section Q.
This Section is not for all members
Only complete this section if you selected one-time lump-sum (#1) or a 5-year installment (#2) in Section P.
1.
q Do not roll over. Send distribution(s) directly to me, or direct deposit to my bank account. Continue to Section R.
2.
q Roll over my distribution(s).
Subsections 2a, 2b, and 2c must be completed. Complete one line only under each 2a and 2b.
2a. Roll over ________________ % of my distribution, or
Roll over $ _______________of my distribution.
2b. Roll to:
q Traditional IRA.
q Roth IRA.
q Oregon Savings Growth Plan (OSGP).
You must be a current OSGP participant to roll over your installment(s) to OSGP.
q Another deferred compensation or employer plan.
You must have an authorized representative of the plan complete the IAP Direct Transfer
Rollover Acceptance form and submit it with your application if you check this box.
2c. List the name of your nancial institution or employer plan name for your rollover below.
Form #459-364 (3/6/2024) SL3 IIM Code: 2163
Page 6 of 7
Applicant’s signature (Required for Section R: IAP beneciary designation)
Date
First name (required) MI Last name (required) Social Security number (required)
Section R: IAP beneciary designation (Required - Select only one Standard or Specic)
I understand this beneciary designation becomes eective on my retirement date.
q STANDARD - I elect to use the Standard beneciary designation. Do not complete table below.
q SPECIFIC - I elect to use the Specic beneciary designation. Complete the table below.
Return completed application, additional forms and documents to PERS at PO Box 23700, Tigard OR 97281-3700, or fax
to 503-598-0561.
q
Check this box if you want PERS to apply the following: If any of the named primary beneciaries predecease
me and I have not named an alternate beneciary, I want the portion of my benet that was designated to that
beneciary shared equally among the remaining primary beneciaries living at my death.
Specic Primary beneciary #1 If living; otherwise, to #1 alternate beneciary(ies).
#1
Full name Social Security # Date of birth Phone Percentage
q Person
q C h a r i t y
q Estate
q Trust
Email or address Relationship
Alternate beneciary(ies) for Primary #1 Alternate percentages must equal percentage assigned to primary #1
#1a
Full name Social Security # Date of birth Phone Percentage
q Person
q C h a r i t y
q Estate
q Trust
Email or address Relationship
#1b
Full name Social Security # Date of birth Phone Percentage
q Person
q C h a r i t y
q Estate
q Trust
Email or address Relationship
Specic Primary beneciary #2 If living; otherwise, to #2 alternate beneciary(ies).
#2
Full name Social Security # Date of birth Phone Percentage
q Person
q C h a r i t y
q Estate
q Trust
Email or address Relationship
Alternate beneciary(ies) for Primary #2 Alternate percentages must equal percentage assigned to primary #2
#2a
Full name Social Security # Date of birth Phone Percentage
q Person
q C h a r i t y
q Estate
q Trust
Email or address Relationship
#2b
Full name Social Security # Date of birth Phone Percentage
q Person
q C h a r i t y
q Estate
q Trust
Email or address Relationship
Form #459-364 (3/6/2024) SL3 IIM Code: 2163
Page 7 of 7
Page 1 of 4
Form W-4P
(2024)
Form W-4P
Department of the Treasury
Internal Revenue Service
Complete and sign both parts of this form and mail to: PERS, PO Box 23700, Tigard, OR 97281-3700 or fax to 503-598-0561
Account type (Select all that apply for this withholding). To indicate dierent withholdings for each account, complete a separate form W-4P for each account.
q
Pension (Tier One/Tier Two / OPSRP)
q
IAP installments of 10 years or longer
q
Alternate payee benet
q
Judge member benet
For Privacy Act and Paperwork Reduction Act Notice, see Instructions and worksheets page 4
*Providing your Social Security number (SSN) is mandatory, and PERS is authorized to request it under provisions of the Internal Revenue code. It will primarily be used to comply with mandatory IRS
reporting. It could also be used for conrmation purposes or recovery of overpaid funds.
Cat. No. 10225T.
Form W-4P
Department of the Treasury
Internal Revenue Service
Part A
Withholding Certificate
for Periodic Pension or Annuity Payments
Give Form W-4P to the payer of your pension or annuity payments.
OMB No. 1545-0074
2024
Step 1:
Enter
Personal
information
(a) First name and middle initial Last name
(b) Social Security number (SSN)*
Address
SSN required.
Forms without SSN
will be rejected
City or town, state, and ZIP code
(c)
Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 3 for more information on each step, when to use the estimator at www.irs.
gov/W4App, and how to elect
to have no federal income tax withheld (if permitted).
Step 2:
Income From
a Job and/or
Multiple
Pensions/
Annuities
(Including a
Spouse’s Job/
Pension/
Annuity)
Complete this step if you (1) have income from a job or more than one pension/annuity, or (2) are married ling jointly and your spouse
receives income from a job or a pension/annuity. See page 3 for examples on how to complete Step 2.
Do only one of the following.
(a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3–4). If you or
your spouse have self-employment income, use this option; or
(b) Complete the items below.
(i) If you (and/or your spouse) have one or more jobs, then enter the total taxable annual pay from all jobs, plus
any income entered on Form W-4, Step 4(a), for the jobs less the deductions entered on Form W-4, Step 4(b), for
the jobs. Otherwise, enter “-0-".....................................................................................................................................
▶ $ ____________
(ii) If you (and/or your spouse) have any other pensions/annuities that pay less annually than this one, then enter
the total annual taxable payments from all lower-paying pensions/annuities. Otherwise, enter “-0-"......................... ▶ $ _____________
(iii) Add the amounts from items (i) and (ii) and enter the total here ................................................................................ ▶ $ _____________
TIP: To be accurate, submit a new Form W-4P for all other pensions/annuities if you haven’t updated your withholding since 2021 or this is a new
pension/annuity that pays less than the other(s). Submit a new Form W-4 for your job(s) if you have not updated your withholding since 2019.
Complete Steps 3–4(b) on this form only if (b)(i) is blank and this pension/annuity pays the most annually. Otherwise, do not complete Steps 3–4(b) on this form.
Step 3:
Claim Dependent
and Other
Credits
If your total income will be $200,000 or less ($400,000 or less if married ling jointly):
Multiply the number of qualifying children under age 17 by $2,000.................................
Multiply the number of other dependents by $500 ............................................................
Add other credits, such as foreign tax credit and education tax credits .................................................
Add the amounts for qualifying children, other dependents, and other credits and enter the total here .......................................
Step 4
(optional):
Other
Adjustments
(a) Other income (not from jobs or pension/annuity payments). If you want tax withheld on other income you
expect this year that won’t have withholding, enter the amount of other income here. This may include interest,
taxable social security, and dividends ........................................................................................................................
(b) Deductions. If you expect to claim deductions other than the basic standard deduction and want to reduce your
withholding, use the Deductions Worksheet on page 4 and enter the result here .................................................................
(c) Extra withholding. Enter any additional tax you want withheld from each payment ............................................
Step 5:
Sign
Here
3 $
4(a) $
4(b)
$
4(c)
$
▶ $ ________________
▶ $ ________________
▶ $ ________________
q
Tier One/Tier Two P&F unit benefit
q
Beneciary benet
q
Disability benet
______________________________________________________ _____________________________
Your signature (This form is not valid unless you sign it.) Date
▶
▶
q
Single or Married filing separately
q Married filing jointly or Qualifying surviving spouse
q Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a
qualifying individual.)
*Providing your Social Security number (SSN) is mandatory, and PERS is authorized to request it under provisions of the Internal Revenue code. It will primarily be used to
comply with mandatory IRS reporting. It could also be used for conrmation purposes or recovery of overpaid funds.
Form OR W-4
Part B
Oregon Withholding Statement and Exemption
Certificate
Oregon Department of Revenue Page 1 of 1 150-101-402 (Rev. 08-18-23, ver. 01)
202024
First name and middle initial Last name Social Security number*
q Redetermination
Home address (number and street or rural route)
SSN required.
Forms without SSN
will be rejected
City or town, state, and ZIP code
Oregon State tax withholding will be calculated based upon single marital status and zero allowances
unless you complete Part B or have an existing Oregon State tax withholding on le with PERS.
See attached Form OR-W-4 Instructions following the federal instructions.
Non-Oregon residents who do not want Oregon State income tax withheld should
enter exemption code M on line 4a and write “Exempt” on line 4b in Part B.
Oregon residents see other exemption codes on page 3 of OR-W-4 instructions.
Important!
Part A will not be processed if either your SSN or your signature is missing from Part A.
Part B will not be processed if either your SSN or your signature is missing from Part B.
Note Your eligibility to claim a certain number of allowances or an exemption from withholding may be subject to review by the Oregon
Department or Revenue. Your employer may be required to send a copy of this form to the department for review.
1
Select one:
q
Single
q
Married
q
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 non-U.S. citizen without permanent resident status.
2 Allowances. Total number of allowances you’re claiming on line A4, B15, or C5. See worksheets in the instructions.
If you skip the worksheets and aren't exempt, enter 0...................................................................................................... 2. _______________
3 Additional amount, if any, you want withheld from each paycheck...............................................................................
3. _____________.00
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 your exemption code. (See instructions).........................................................................................................
• Write “Exempt”..........................................................................................................................................................
4a. ______________
4b. ______________
Sign here. Under penalty of false swearing, I declare that the information provided is true, correct, and complete.
Employee’s signature (This form isn’t valid unless signed) Date
Page 2 of 4
Form W-4P
Page 3 of 4
General instructions
Section references are to the Internal Revenue Code
.
Future developments. For the latest information about any future
developments related to Form W-4P, such as legislation enacted after it
was published, go to www.irs.gov/FormW4P.
Purpose of form. Complete Form W-4P to have payers withhold the
correct amount of federal income tax from your periodic pension, annuity
(including commercial annuities), prot-sharing and stock bonus plan, or
IRA payments. Federal income tax withholding applies to the taxable part
of these payments. Periodic payments are made in installments at regular
intervals (for example, annually, quarterly, or monthly) over a period of
more than 1 year. Don’t use Form W-4P for a nonperiodic payment (note
that distributions from an IRA that are payable on demand are treated
as nonperiodic payments) or an eligible rollover distribution (including
a lump-sum pension payment). Instead, use Form W-4R, Withholding
Certicate for Nonperiodic Payments and Eligible Rollover Distributions,
for these payments/distributions. For more information on withholding,
see Pub. 505, Tax Withholding and Estimated Tax.
Choosing not to have income tax withheld. You can choose not to
have federal income tax withheld from your payments by writing “No
Withholding” on Form W-4P in the space below Step 4(c). Then, complete
Steps 1a, 1b, and 5. Generally, if you are a U.S. citizen or a resident alien,
you are not permitted to elect not to have federal income tax withheld on
payments to be delivered outside the United States and its territories.
Caution: If you have too little tax withheld, you will generally owe tax
when you le your tax return and may owe a penalty unless you make
timely payments of estimated tax. If too much tax is withheld, you will
generally be due a refund when you le your tax return. If your tax
situation changes, or you chose not to have federal income tax withheld
and you now want withholding, you should submit a new Form W-4P.
When to use the estimator. Consider using the estimator at www.irs.
gov/W4App if you:
1. Have social security, dividend, capital gain, or business income, or are
subject to the Additional Medicare Tax or Net Investment Income Tax; or
2. Receive these payments or pension and annuity payments for only part
of the year.
Self-employment. Generally, you will owe both income and self-
employment taxes on any self-employment income you (or you and your
spouse) receive. If you do not have a job and want to pay these taxes
through withholding from your payments, use the estimator at www.irs.
gov/W4App to gure the amount to have withheld.
Payments to nonresident aliens and foreign estates. Do not use Form
W-4P. See Pub. 515, Withholding of Tax on Nonresident Aliens and
Foreign Entities, and Pub. 519, U.S. Tax Guide for Aliens, for more
information.
Tax relief for victims of terrorist attacks. If your disability payments
for injuries incurred as a direct result of a terrorist attack are not taxable,
write “No Withholding” in the space below Step 4(c). See Pub. 3920,
Tax Relief for Victims of Terrorist Attacks, for more details.
Specic Instructions
Step 1(c). Check your anticipated ling status. This will determine the
standard deduction and tax rates used to compute your withholding.
Step 2. Use this step if you have at least one of the following: income
from a job, income from more than one pension/annuity, and/or a spouse
(if married filing jointly) that receives income from a job/pension/
annuity. The following examples will assist you in completing Step 2(b).
Example 1. Bob, a single ler, is completing Form W-4P for a pension
that pays $50,000 a year. Bob also has a job that pays $25,000 a year.
Bob has no other pensions or annuities. Bob will enter $25,000 in Step
2(b)(i) and in Step 2(b)(iii).
If Bob also has $1,000 of interest income, which he entered on Form
W-4, Step 4(a), then he will instead enter $26,000 in Step 2(b)(i) and in
Step 2(b)(iii). He will make no entries in Step 4(a) on this Form W-4P.
Example 2. Carol, a single ler, is completing Form W-4P for a pension that
pays $50,000 a year. Carol does not have a job, but she also receives another
pension for $25,000 a year (which pays less annually than the $50,000
pension). Carol will enter $25,000 in Step 2(b)(ii) and in Step 2(b)(iii).
If Carol also has $1,000 of interest income, then she will enter $1,000 in
Step 4(a) of this Form W-4P.
Example 3. Don, a single ler, is completing Form W-4P for a pension
that pays $50,000 a year. Don does not have a job, but he receives
another pension for $75,000 a year (which pays more annually than the
$50,000 pension). Don will not enter any amounts in Step 2.
If Don also has $1,000 of interest income, he won’t enter that amount on
this Form W-4P because he entered the $1,000 on the Form W-4P for the
higher paying $75,000 pension.
Example 4. Ann, a single ler, is completing Form W-4P for a pension
that pays $50,000 a year. Ann also has a job that pays $25,000 a year and
another pension that pays $20,000 a year. Ann will enter $25,000 in Step
2(b)(i), $20,000 in Step 2(b)(ii), and $45,000 in Step 2(b)(iii).
If Ann also has $1,000 of interest income, which she entered on Form
W-4, Step 4(a), she will instead enter $26,000 in Step 2(b)(i), leave Step
2(b)(ii) unchanged, and enter $46,000 in Step 2(b)(iii). She will make no
entries in Step 4(a) of this Form W-4P.
If you are married ling jointly, the entries described above do not
change if your spouse is the one who has the job or the other pension/
annuity instead of you.
Multiple sources of pensions/annuities or jobs. If you
(or if married ling jointly, you and/or your spouse) have a
job(s), do NOT complete Steps 3 through 4(b) on Form W-4P.
Instead, complete Steps 3 through 4(b) on the Form W-4 for
the job. If you (or if married ling jointly, you and your spouse) do not
have a job, complete Steps 3 through 4(b) on Form W-4P for only the
pension/annuity that pays the most annually. Leave those steps blank for
the other pensions/annuities.
Step 3. This step provides instructions for determining the amount of
the child tax credit and the credit for other dependents that you may be
able to claim when you le your tax return. To qualify for the child tax
credit, the child must be under age 17 as of December 31, must be your
dependent who generally lives with you for more than half the year,
and must have the required social security number. You may be able to
claim a credit for other dependents for whom a child tax credit can’t be
claimed, such as an older child or a qualifying relative. For additional
eligibility requirements for these credits, see Pub. 501, Dependents,
Standard Deduction, and Filing Information. You can also include other
tax credits for which you are eligible in this step, such as the foreign tax
credit and the education tax credits. Including these credits will increase
your payments and reduce the amount of any refund you may receive
when you le your tax return.
Step 4 (optional).
Step 4(a). Enter in this step the total of your other estimated income
for the year, if any. You shouldn’t include amounts from any job(s) or
pension/annuity payments. If you complete Step 4(a), you likely won’t
have to make estimated tax payments for that income. If you prefer to
pay estimated tax rather than having tax on other income withheld from
your pension, see Form 1040-ES, Estimated Tax for Individuals.
Step 4(b). Enter in this step the amount from the Deductions Worksheet,
line 6, if you expect to claim deductions other than the basic standard
deduction on your 2024 tax return and want to reduce your withholding
to account for these deductions.
This includes itemized deductions, the additional standard deduction for those
65 and over, and other deductions such as for student loan interest and IRAs.
Step 4(c). Enter in this step any additional tax you want withheld from
each payment. Entering an amount here will reduce your payments and
will either increase your refund or reduce any amount of tax that you owe.
Note: If you don’t give Form W-4P to your payer, you don’t provide an
SSN, or the IRS notifies the payer that you gave an incorrect SSN, then
the payer will withhold tax from your payments as if your filing status
is single with no adjustments in Steps 2 through 4. For payments that
began before 2024, your current withholding election (or your default
rate) remains in effect unless you submit a new Form W-4P.
Step 4(b)—Deductions Worksheet (Keep for your records.)
1
Enter an estimate of your 2024 itemized deductions (from Schedule A (Form 1040)). Such
deductions may include qualifying home mortgage interest, charitable contributions, state and
local taxes (up to $10,000), and medical expenses in excess of 7.5% of your income ...................... 1 $ _________
2
• $29,200 if you’re married ling jointly or qualifying surviving spouse
• $21,900 if you’re head of household ...............
• $14,600 if you’re single or married ling separately
2 $ _________
3
If line 1 is greater than line 2, subtract line 2 from line 1 and enter the result here. If line 2 is
greater than line 1, enter “-0-” ............................................................................................................ 3 $ _________
4
If line 3 equals zero, and you (or your spouse) are 65 or older, enter:
• $1,950 if you’re single or head of household.
• $1,550 if you’re married ling separately.
• $1,550 if you’re a qualifying surviving spouse or you’re married ling jointly and one of you is
under age 65.
• $3,100 if you’re married ling jointly and both of you are age 65 or older. Otherwise,
enter “-0-”. See Pub. 505 for more information ...............................................................................
4 $ _________
5 Enter an estimate of your student loan interest, deductible IRA contributions, and certain
other adjustments (from Part II of Schedule 1 (Form 1040)). See Pub. 505 for more information ... 5 $ _________
6 Add lines 3 through 5. Enter the result here and in Step 4(b) on Form W-4P ................................... 6 $ _________
Enter
{
Privacy Act and Paperwork Reduction Act Notice. We
ask for the information on this form to carry out the Internal
Revenue laws of the United States. You are required to
provide this information only if you want to (a) request
federal income tax withholding from pension or annuity
payments based on your ling status and adjustments; (b)
request additional federal income tax withholding from
your pension or annuity payments; (c) choose not to have
federal income tax withheld, when permitted; or (d) change
a previous Form W-4P. To do any of the aforementioned,
you are required by sections 3405(e) and 6109 and their
regulations to provide the information requested on this
form. Failure to provide this information may result in
inaccurate withholding on your payment(s). Failure to
provide a properly completed form will result in your being
treated as a single person with no other entries on the form;
providing fraudulent information may subject you to
penalties.
Routine uses of this information include giving it to the
Department of Justice for civil and criminal litigation,
and to cities, states, the District of Columbia, and U.S.
commonwealths and territories for use in administering
their tax laws. We may also disclose this information to
other countries under a tax treaty, to federal and state
agencies to enforce federal nontax criminal laws, or to
federal law enforcement and intelligence agencies to
combat terrorism.
You are not required to provide the information requested
on a form that is subject to the Paperwork Reduction Act
unless the form displays a valid OMB control number.
Books or records relating to a form or its instructions
must be retained as long as their contents may become
material in the administration of any Internal Revenue
law. Generally, tax returns and return information are
condential, as required by section 6103.
The average time and expenses required to complete
and le this form will vary depending on individual
circumstances. For estimated averages, see the instructions
for your income tax return.
If you have suggestions for making this form simpler, we
would be happy to hear from you. See the instructions for
your income tax return.
Page 4 of 4
{
1 of 7
2024 Form OR-W-4 Instructions
Purpose of this form
Use Form OR-W-4 to tell your employer or other payer how
much Oregon income tax to withhold from your wages or
other periodic income.
Instructions for employer or other payer. Enter the business
name, federal employer identification number (FEIN), and
address in the “Employer use only” section of Form OR-W-
4. Keep the completed form with your records. For more
information and additional instructions, see Publication
150-211-602, W-4 Information for Employers, and the additional
resources listed on page 4.
Complete Form OR-W-4 if:
• You’re starting a new job with an employer who must
withhold Oregon tax from your pay.
• You’re receiving a pension or annuity and the payer must
withhold Oregon tax from each payment.
• You’ve had a recent personal or financial change that
affects your taxes, such as a change in your income, filing
status, or number of dependents.
• You weren’t satisfied with the amount of Oregon tax you
owed or had refunded to you when you filed a recent
return.
• You filed a federal Form W-4 with your employer after
2017 that didn’t specify withholding allowances for
Oregon.
The worksheets in these instructions are designed to help
you estimate the amount of Oregon tax your employer
should withhold from your pay. For a more accurate esti-
mate, use the Oregon Withholding Calculator at www.
oregon.gov/dor before you complete Form OR-W-4.
Pension and annuity withholding. Use Form OR-W-4 to des-
ignate the Oregon withholding from your pension, annuity,
or other periodic payments.
Questions to consider:
• Do you (including your spouse) have more than one job?
• Do you expect your wages or your total income for 2024 to
be more than $100,000 (or $200,000 if you’re married and
will file a joint return with your spouse, or you’re a recent
widow(er)?
• Are you making mid-year changes to your withholding?
• Do you receive pension or annuity payments?
•
Do you live outside Oregon, or did you move to Oregon this
year?
•
Are you a non-U.S. citizen without permanent resident status?
If you answered yes to any of these questions, read
the “Specific information” section in these instruc-
tions before completing the worksheets or Form
OR-W-4. Consider using the online Oregon Withholding
Calculator at www.oregon.gov/dor instead of the work-
sheets for more accurate results.
General information
What is Oregon income tax withholding?
Oregon income tax must be paid during the year as you earn
or receive your income. Employers and certain other pay-
ers are required by law to set aside (withhold) part of your
paycheck or other payment for taxes that they send to the
Department of Revenue on your behalf every time they pay
you. “Withholding” refers to the portion of income that your
employer or other payer holds back from each paycheck or
other payment.
How is the amount of Oregon income tax
withholding determined?
The amount that the employer or other payer must withhold
depends on several things, such as:
• Your income.
• Your marital status.
• The number of children or other dependents you have.
Allowances. Depending on your situation, some of your
income might not be subject to withholding. Each allowance
reduces the amount of income that is withheld from each
payment. The worksheets in these instructions will help you
determine how many allowances you may claim.
Additional withholding. You may want to have more money
withheld from each payment. If you have other income that
isn’t subject to withholding, requesting additional withhold-
ing on Form OR-W-4 may help you avoid owing tax on that
other income when you file your tax return.
You report your marital status, allowances, and any addi-
tional amount you want withheld by completing Form
OR-W-4 and submitting it to your employer or other payer.
They will use this information, along with Publication 150-
206-436, Oregon Withholding Tax Formulas, to withhold a
specific amount each pay period.
What if too much or not enough is withheld?
If you have too much tax withheld, you may have a refund
when you file your tax return. This is money that you
couldn’t use during the year when you might have needed it.
If you have too little tax withheld, you may owe tax when
you file your tax return, plus penalty and interest. This is
money that you might have used during the year but will
need to pay when you file your return after the year ends.
See Publication OR-17 for penalty and interest information.
Why can’t the federal form be used for all
withholding?
Oregon employees used to be able to use federal Form W-4
for both their federal and Oregon withholding. In 2020, the
Internal Revenue Service made some major changes to the
STOP
Form OR-W-4 Instructions
Oregon Withholding Statement
and Exemption Certificate
2024
2 of 7
2024 Form OR-W-4 Instructions
way that federal withholding is done. They changed Form
W-4 in such a way that it can no longer be used for Oregon
withholding purposes. Similar changes were made to Form
W-4P, for withholding from pensions and annuities, starting
in 2022. You must use Oregon’s Form OR-W-4 instead.
How often does Form OR-W-4 have to be submitted?
Complete and submit a new Form OR-W-4 when you start
a new job and whenever your tax situation changes. This
includes changes in your income, marital status, and number
of dependents.
Note: If you are claiming an exemption from Oregon with-
holding, you must submit a new Form OR-W-4 by February
15 every year if you continue to qualify for exemption. See
the instructions for line 4.
What will happen if no Form OR-W-4 is submitted?
Your employer or other payer will refer to your most recent
withholding form to determine your withholding. If no Form
OR-W-4 has been submitted, they will withhold for Oregon
based upon the following order:
• An Oregon-only version of the federal Form W-4 for a year
prior to 2020, or federal Form W-4P for a year prior to 2022.
• Federal Form W-4 for a year prior to 2020, or Form W-4P
for a year prior to 2022.
• Eight percent of your wages or other income subject to
withholding.
What will happen if the information on the form
is false?
You may be assessed a penalty of $500 if there is no reason-
able basis for the instructions you’re giving your employer
or other payer using Form OR-W-4.
Specific information
Two earners or multiple jobs. See the instructions for Work-
sheet C or use the online withholding calculator if you have
more than one job at a time or will file a joint return with a
working spouse.
Wages or adjusted gross income (AGI)* that exceed the
threshold. Your income level affects your withholding. Do
you expect to have wages or AGI on your 2024 return that
are more than $100,000 (or $200,000 if using the married fil-
ing jointly or the qualifying surviving spouse filing status)?
If so, you may want to request additional withholding.
Consider using the online calculator to determine the correct
amount to put on your Form OR-W-4.
*Helpful tip: AGI. Your AGI is your total income minus
federal adjustments to income. This amount on your 2023
federal Form 1040 may help you estimate your 2024 AGI.
Mid-year changes. If you claimed too many allowances for
the first part of the year, your withholding may not cover
all of your tax when you file your return. Use the online
calculator to determine the additional amount you need
withheld to make up for the shortage. If you don’t change
your withholding, you may owe tax, penalties, and interest
when you file your return. See Publication OR-17 for penalty
and interest information.
Pension or annuity payments. If you’ve opted out of federal
withholding from a pension, annuity, or other periodic pay-
ment, you’re automatically opted out of Oregon withholding
also. If you’re not having tax withheld from this income, you
may be required to make estimated tax payments. See Publi-
cation OR-ESTIMATE to determine the amount of estimated
tax payments you need to make.
If you elect to have Oregon tax withheld from your pension
or annuity payment, where the tax must be withheld at a
certain percentage, you can’t claim allowances on Form
OR-W-4, but you may request additional withholding.
Exemption from withholding. You may be in a situation
where none of your income is subject to Oregon tax. In that
case, your income may be exempt from withholding. The
exemption period depends on the type of income you have.
For wages, the exemption ends on February 15th of the fol-
lowing year. For commercial annuities, employer deferred
compensation plans, and individual retirement plans where
an election to have no withholding may be made, the exemp-
tion ends when you notify the payer in writing that you
revoke the election. See the instructions for line 4.
Part-year and nonresidents. Have you recently moved to
Oregon, or do you live outside the state? If so, you’ll report
your Oregon income and deductions in the Oregon col-
umn of your part-year or nonresident tax return. Use only
the amounts that will be in the Oregon column when you
complete Worksheet B or C, or use the online withholding
calculator for more accurate results.
Non-U.S. citizen without permanent resident status. If all or
a portion of your wages are exempt from federal withhold-
ing, these wages are also completely or partially exempt from
Oregon withholding. Submit federal exemption Form 8233
to your employer to exempt all or part of your wages from
Oregon withholding.
If any portion of your wages is not exempt, submit Form
OR-W-4 to your employer. You may not qualify to claim
certain deductions from your Oregon income, so you will
need to take extra steps to ensure that your withholding is
adequate. Follow the instructions below when completing
Form OR-W-4:
• Line 1. Check the “single” box regardless of your marital
status.
• Line 2. Usually, you should claim -0- withholding allow-
ances. However, if you complete the worksheets, follow
the instructions below.
— Complete Worksheet B using amounts that will be
included in the Oregon column of your return.
— Once you have completed all applicable worksheets,
subtract 1 allowance from the number on line A4, B15,
or C5.
• Line 4. Don’t claim exempt due to “no tax liability” or for
the portion of your wages exempted on federal Form 8233.
3 of 7
2024 Form OR-W-4 Instructions
Form OR-W-4 line instructions
For the form and all worksheet instructions, terms such
as “pay,” “paycheck,” and “wages” also refer to pensions,
annuities, and other periodic payments, and the word
“employer” also refers to other payers.
Type or clearly print your name, Social Security number
(SSN), and mailing address.
Note. You must enter an SSN. You can’t use an individual
taxpayer identification number (ITIN).
Redetermination check box. If the department issued a
determination letter to your employer specifying the amount
your employer needs to withhold from your wages and you
want to decrease your withholding, you must have a per-
sonal or financial change affecting your tax situation. If you
do, mark the “Redetermination” check box. Provide a copy
to your employer and send a copy with all of the applicable
worksheets filled out to the department at:
ADP OR-W-4 Project
Oregon Department of Revenue
PO Box 14560
Salem, OR 97309
Line 1. If you anticipate using the single, married filing
separately, or head of household filing status when you file
your 2024 return, mark “Single.”
If you anticipate using the married filing jointly or qualify-
ing surviving spouse filing status when you file your 2024
return, mark “Married.” If you meet the married filing jointly
qualifications, but want tax withheld at the higher “single”
rate, mark “Married, but withhold at the higher single rate.”
For the qualifications of each filing status, see federal Publica-
tion 501, Exemptions, Standard Deduction, and Filing Information.
Line 2. Complete all applicable worksheets. Enter the allow-
ances from Worksheet A, line A4, Worksheet B, line B15, or
Worksheet C, line C5.
Line 3. If you choose to have an additional amount withheld
from your pay, enter the amount that you want withheld
from each paycheck. If you completed Worksheet C, line C8
may direct you to claim an additional amount per paycheck.
Line 4. If you’re claiming exemption from withholding, you
must meet one of these requirements:
• Your wages must be exempt from Oregon taxation, or
• You must meet the qualification for having no tax liability.
To claim exemption due to no tax liability, you must meet
both of the following conditions:
• Last year you had the right to a refund of all Oregon tax
withheld because you had no tax liability, and
• This year you expect a refund of all Oregon income tax
withheld because you expect to have no tax liability.
To claim exempt, enter the corresponding code from the
Exemption chart on line 4a. Enter only one exemption code,
even if more than one applies. Write “Exempt” on line 4b.
Note: For wages, exemptions end February 15th of the fol-
lowing year. A new Form OR-W-4 must be completed and
submitted to your employer each year.
Exemption chart
Exemption Code
Air carrier employee A
American Indian enrolled tribal member living and
working in Indian country in Oregon.
B
Amtrak Act worker C
Casual laborer D
Domestic service worker E
Hydroelectric dam worker at the Bonneville, John Day,
McNary, or The Dalles dam.
F
Military pay for nonresidents stationed in Oregon and
their spouses, residents stationed outside Oregon, and
service members or spouses treated as nonresidents
for tax purposes.
G
Minister who is duly ordained, commissioned, or licensed
and performing duties in their ministry or a member of a
religious order performing duties required by their order.
H
Real estate salesperson under a written contract not
to be treated as an employee.
J
Waterway worker K
No tax liability. See above for definition. L
Nonresident who expects a refund of all Oregon income
tax withheld because their wages won’t be subject to
Oregon tax.
M
Sign and date Form OR-W-4. Submit Form OR-W-4 to your
employer. Don’t complete the employer’s information. Keep
the worksheets with your tax records.
Worksheet instructions
Worksheet A—Personal allowances
Note: If your annual wages from this job are more than
$100,000 and you’re marking “Single” or “Married, but with-
hold at the higher single rate” ($200,000 if you’re marking
“Married”), skip Worksheet A and claim zero allowances on
Form OR-W-4.
Line A3. Dependents. Enter the total number of all qualify-
ing children and qualifying relatives you are able to claim
as dependents on your Oregon return. See the “Exemp-
tion credit” section of Publication OR-17 for dependent
qualifications.
Worksheet B—Deductions, adjustments, credits,
and nonwage income
Line B1. If you have large amounts of nonwage income, such
as interest, dividends, or self-employment income, consider
making estimated tax payments. For required payments and
other information, see Publication OR-ESTIMATE. You may
also request additional withholding from each paycheck.
Otherwise, you may owe additional tax when you file your
return, together with interest on any underpayment of
required estimated tax payments.
4 of 7
2024 Form OR-W-4 Instructions
Line B2. Additions are generally items the federal govern-
ment doesn’t tax but Oregon does. See Publication OR-17
for a list of additions and instructions.
Line B4. Enter your anticipated 2024 Oregon deductions. If
you don’t know your anticipated 2024 deductions, enter the
standard deduction for your anticipated filing status.
The 2024 standard deduction for each filing status is:
• $2,745 for single or married filing separately.
• $4,420 for head of household.
• $5,495 for married filing jointly or qualifying surviving
spouse.
If you qualify for an additional standard deduction amount
because you or your spouse are age 65 or older or blind, and
you don’t plan to itemize your deductions, add the addi-
tional amount to your anticipated deduction amount on line
B4. If you’re married (or a qualifying surviving spouse), the
additional standard deduction is $1,000; for everyone else,
the additional amount is $1,200.
Itemized deductions include items such as medical expenses
that are more than 7 1/2 percent of your AGI, state and local
taxes you paid (limited to $10,000, but don’t include Oregon
income taxes), qualifying home mortgage interest, charitable
contributions, and certain miscellaneous deductions. If you
plan to itemize your deductions, enter your estimated Oregon
itemized deductions. See Schedule OR-A Instructions for
more information.
Line B7. Adjustments to income reduce your gross income,
resulting in AGI on your federal return. See the instructions
for federal Form 1040 and the “Adjustments” section of
Publication OR-17 for more information.
Subtractions are generally items the federal government
taxes but Oregon doesn’t. See Publication OR-17 for a list
of subtractions and instructions. Don’t include your federal
tax subtraction.
Line B10. Divide line B9 by $3,200. Round to one decimal
place. For example, round 4.84 to 4.8 and 4.85 to 4.9. This
calculation converts the amount from line B9 into allowances.
Line B11. Credits reduce the amount of tax you must pay.
Standard and carryfoward credits can reduce your tax to
zero but can’t be refunded to you. Refundable credits can
reduce your tax to zero and also result in a refund of any
remaining amount. See Publication OR-17 for a list of credits
and instructions.
Enter an estimate of the credits you will claim on your 2024
Oregon return. Don’t include your exemption credits.
Line B12. Divide line B11 by $249. Round using one decimal
place. For example, round 4.84 to 4.8 and 4.85 to 4.9. This
calculation converts the amount from B11 into allowances.
Line B13. Add lines B10 and B12. Round to the nearest whole
number that is closer to zero by eliminating the decimal value.
For example, round 4.3 or 4.8 to 4 and round -3.3 or -3.7 to -3.
Example 1. Roger entered -3.1 on line B10. He entered 2.4 on
line B12. He will enter -0- on line B13 (-3.1 + 2.4 = -0.7, which
is rounded to 0).
Line B15. If the result when you add lines B13 and B14 is
less than zero, you may owe tax when you file your return.
Request additional withholding or consider making esti-
mated tax payments to avoid owing tax plus potential
penalties and interest. See Publication OR-ESTIMATE for
information about estimated payments.
Worksheet C—Two earners / multiple jobs
Use Worksheet C if you work more than one job at a time or
you have a working spouse.
Line C5. For your highest paying job, enter the result of
Worksheet C, line C5 on Form OR-W-4, line 2. For all of your
lower paying jobs, claim zero allowances.
Line C8. For your highest paying job, enter the result of
Worksheet C, line C8 on Form OR-W-4, line 3. Round to the
nearest whole dollar. For all of your lower paying jobs, claim
zero as the additional amount to be withheld.
Example 2. Todd is completing this form in January and has
entered $824 on line C7. For his highest paying job, he is paid
every two weeks and has 25 paychecks left for the year. Todd
will enter $33 on line C8 and Form OR-W-4, line 3 ($824 ÷ 25
= $32.96, which is rounded up to the nearest whole dollar).
Additional resources
For additional information, refer to the following publications:
• Publication 150-206-436, Oregon Withholding Tax Formulas.
• Publication OR-17, Oregon Individual Income Tax Guide.
• Publication OR-ESTIMATE, Instructions for Estimated Income Tax.
• Publication 150-211-602, W-4 Information for Employers.
• Federal Pub. 501, Exemptions, Standard Deduction, and Fil-
ing Information.
• Federal Form 2833, Exemption From Withholding on Compensa-
tion for Independent (and Certain Dependent) Personal Services
of a Nonresident Alien Individual.
• Federal Form 1040 Instructions.
Do you have questions or need help?
www.oregon.gov/dor
503-378-4988 or 800-356-4222
questions.dor@ dor.oregon.gov
Contact us for ADA accommodations or assistance in other
languages.
2024 Form OR-W-4 Instructions
Note: If you marked “Single” or “Married, but withhold at higher single rate” and your annual wages for this job will be
more than $100,000 ($200,000 if you marked “Married”), skip lines A1 through A3 and enter 0 on line A4.
A1. Enter “1” for yourself if no one else can claim you as a dependent. Otherwise, enter 0.................... A1.
A2. Enter “1” for your spouse if your spouse isn’t employed. Otherwise, enter 0 ................................... A2.
A3. Enter the number of dependents you will claim on your Oregon tax return ....................................... A3.
A4. Add lines A1 through A3. Enter the result here and follow the instructions below .............................. A4.
Complete all worksheets that apply.
• Worksheet B—Use this worksheet if you plan to do any of the following on your 2024 Oregon return:
o Itemize your Oregon deductions or claim additional standard deduction amounts.
o Claim federal adjustments to income or Oregon additions, subtractions, or credits (other than personal exemption credits).
o Report nonwage income (such as dividends, interest, or self-employment income).
• Worksheet C—Use this worksheet if you (including your spouse) have more than one job and the combined earnings from
all jobs exceed $20,000.
If neither of the above worksheets apply, stop here and enter the number from line A4 on Form OR-W-4, line 2.
Worksheet A—Personal allowances
– Keep this worksheet for your records –
5 of 7
STOP
2024 Form OR-W-4 Instructions
Use this worksheet if you plan to do any of the following on your 2024 Oregon return:
• Itemize your Oregon deductions or claim additional standard deduction amounts.
• Claim federal adjustments to income or Oregon additions, subtractions, or credits (other than personal exemption credits).
• Report nonwage income (such as dividends, interest, or self-employment income).
Having your most recent Oregon tax return on hand may help you when completing this worksheet.
Don’t use negative numbers unless otherwise instructed. For example, write a $1,000 Oregon subtraction as “$1,000”, not
“($1,000)” or “-$1,000”. For more information, see the instructions for this worksheet starting on page 3.
B1. Enter your estimated 2024 nonwage income (such as dividends or interest) .............B1.
B2. Enter your estimated 2024 Oregon additions ...............................................................B2.
B3. Add lines B1 and B2 .............................................................................................................................B3.
B4. Enter your estimated 2024 Oregon deductions. (See instructions) ..............................B4.
B5. Enter the standard deduction based on your anticipated 2024 filing status: ..............B5.
• Single or Married Filing Separately: $2,745.
• Head of Household: $4,420.
• Married Filing Jointly or Qualifying Surviving Spouse: $5,495.
B6. Line B4 minus line B5. If the result is zero or less, enter 0 ...................................................................B6.
B7. Enter your estimated 2024 federal adjustments to income and Oregon subtractions
(exception—don’t include the federal tax subtraction) ........................................................................B7.
B8. Add lines B6 and B7 .............................................................................................................................B8.
B9. Line B8 minus line B3. If less than zero, enter as a negative amount ..................................................B9.
B10. Line B9 divided by $3,200. Round to one decimal place. If less than zero,
enter as a negative amount.................................................................................................................B10.
B11. Enter your estimated 2024 Oregon standard, carryforward, or refundable
credits (exception—don’t include personal exemption credits) .................................B11.
B12. Divide line B11 by $249. Round to one decimal place .......................................................................B12.
B13. Add lines B10 and B12. If less than zero, enter as a negative amount. Round to
the whole number closest to zero (See instructions) ..........................................................................B13.
B14. Enter the number from Worksheet A, line A4 ....................................................................................B14.
B15. Add lines B13 and B14. If zero or less, enter 0. (See instructions) .....................................................B15.
If you’re using Worksheet C, enter the result from line B15 on Worksheet C, line C1.
Otherwise, stop here and enter the result from line B15 on Form OR-W-4, line 2.
– Keep this worksheet for your records –
6 of 7
Worksheet B—Deductions, adjustments, credits, and nonwage income
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2024 Form OR-W-4 Instructions
If you (including your spouse) work three or more jobs at one time, consider using the Oregon Withholding Calculator at www.
oregon.gov/dor for a more accurate calculation of your allowances.
If you don’t use the online calculator, use this worksheet to figure the number of allowances to claim on the Form OR-W-4 for your highest
paying job. For the best results, we recommend that you claim allowances only on the Form OR-W-4 you submit for your highest paying
job, and that you claim zero allowances on Form OR-W-4, line 2 for all of your (or your spouse’s) other jobs. Doing so will help prevent
under-withholding. For more information, see the instructions for this worksheet starting on page 4.
Complete this worksheet only if you (including your spouse) have more than one job and the combined earnings from all jobs exceed $20,000.
C1. Enter the number from Worksheet B, line B15. If you didn’t use Worksheet B, enter the
number from Worksheet A, line A4 ..................................................................................................... C1.
C2. Enter the indicated number based on your 2024 anticipated filing status ................... C2.
• Single, Head of Household, or Married Filing Separately: Enter “2”;
however, if two of your jobs individually exceed $40,000, enter “4”.
• Married Filing Jointly or Qualifying Surviving Spouse: Enter “3”; however,
if two of your jobs individually exceed $50,000, enter “6”.
C3. If you (including your spouse) will work three or more jobs at the same time at
any point during the year, enter the indicated number for your 2024 anticipated
filing status. Otherwise, enter 0 .................................................................................... C3.
• Single, Head of Household, or Married Filing Separately: Enter “2”.
• Married Filing Jointly or Qualifying Surviving Spouse: Enter “3”.
C4. Add lines C2 and C3 .............................................................................................................................C4.
C5. Is line C1 less than line C4?
• Yes. Enter 0 on line C5 and on Form OR-W-4, line 2. Continue with lines C6 through C8
to figure the additional withholding amount necessary to avoid owing tax with your return.
• No. Line C1 minus line C4. Enter the result on line C5 (if zero, enter 0) and on Form OR-W-4,
line 2. Don’t complete the rest of this worksheet.. ...........................................................................C5.
C6. Line C4 minus line C1 ...........................................................................................................................C6.
C7. Line C6 multiplied by $249 ...................................................................................................................C7.
C8. Line C7 divided by the number of paychecks remaining in 2024 for the highest paying job and
rounded to the nearest dollar. Enter the result here and on Form OR-W-4, line 3. This is the
additional amount to be withheld from each paycheck ....................................................................... C8.
Reminder: If you’re requesting additional withholding for part of the year, remember to check your withholding again early next year.
– Keep this worksheet for your records –
Worksheet C—Two earners / multiple jobs
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Instructions for form #459-001 SL3 (5/2/2024) IIM Code: 2111
PERS encourages you to deposit your benefit payment directly to your bank or other financial institution for all of the
following reasons:
• The deposit should always be on time rather than dependent on mail delivery.
• There is no risk your benefit payment will be stolen or lost.
• If you are on vacation or ill, you will not have to arrange for your benefit to be deposited by someone else.
• Fill this section out completely. Type or print clearly in dark ink. Illegible forms may be returned to applicant.
• Check which plan(s) this automatic deposit applies to.
Note: If you have more than one plan and want the benefits to go to two separate accounts, you must fill out a
separate Domestic Authorization Agreement for Automatic Deposits form for each account.
• Check a box to let us know if the funds will be deposited into a checking, savings, or business account.
• Provide the required information about your account: account number, routing number, and financial institution.
Section A: Applicant information
11410 SW 68th Parkway, Tigard OR 97223
Mailing Address – PO Box 23700, Tigard OR 97281-3700
Toll free – 888-320-7377 Fax – 503-598-0561
Website – https://oregon.gov/pers
Instructions for the Domestic Authorization Agreement for Automatic Deposits
General information
Review the blank check guide for information on where the routing and account numbers are located on your checks.
PERS must coordinate with your financial institution, and your first monthly check may be mailed to you. Future changes to
your account number may result in a monthly check being mailed to you. Therefore, you should always maintain a current
mailing address with PERS via your Online Member Services (OMS) account or by using the Information Change Request
form. Typically, forms received by the 15th of the month will be effective for the following month’s benefit payment.
An information stub will be mailed three times per year to your current mailing address.
Optional — Tape your voided or canceled check to the back of the form. Do not attach a deposit slip.
If faxing, fax voided or canceled check as a separate page 2, labeled with your PERS ID or Social Security number.
Section B: Certication signatures (Required)
• Applicants and joint account holders need to read the certification statements.
It violates this agreement if the entire amount of your direct deposit payment is deposited or transferred to a bank
outside of the U.S. If this situation applies to you, do not complete this form. You must be paid by check.
• Applicant: Sign and date the form. (Required)
• Any and all joint account holders must also sign and date the form. (Required) If more than one joint account
holder exists, each joint account holder’s printed name and signature must be present in the joint account holder’s
certification field. If there are more than two joint account holders, they may sign side by side in the joint account
holder field, or they may each sign on separate forms. However, each form will require the member’s signature and
account information. When joint account holders sign on individual forms, submit all forms together. Include a
death certificate for any deceased joint account holder whose name appears on your voided check.
Form #459-001 SL3 (5/2/2024) IIM Code: 2111
Applicant certification - Required
I certify I have read and understand the information and
instructions on this form. In signing this form, I authorize my
payment to be sent to my financial institution and deposited to
the designated account. I authorize amounts transferred after
my death or transmitted in error to be debited from my account.
If the funds have been withdrawn following my date of death,
I authorize my financial institution to release the name and
address of the person(s) responsible for withdrawing the funds.
Additionally, I certify that the entire amount of my direct deposit is not
deposited or transferred to a foreign financial institution.**
Joint account holder’s certification - Required
I certify I have read this form and understand I must advise
PERS of the death of the above named applicant and that funds
deposited into the account listed below after the date of death are
to be refunded to PERS.
Financial institution address and phone number (optional)
Name of financial institution
Account number (Show the number exactly, including necessary spaces, zeroes, or dashes.)
Routing number
Section C: Revocation instructions
11410 SW 68th Parkway, Tigard OR 97223
Mailing Address – PO Box 23700, Tigard OR 97281-3700
Toll free – 888-320-7377 Fax – 503-598-0561
Website – https://oregon.gov/pers
Domestic Authorization Agreement for Automatic Deposits
First name MI Last name PERS ID (optional)
Mailing address (street or PO box) Social Security number (SSN)*
City State ZIP code Date of birth (mm/dd/yyyy)
Home phone number Work phone number Cell phone number Personal email
Section A: Applicant information (Type or print clearly in dark ink. Illegible forms may be returned to applicant. This could delay your request.)
This form is strictly for direct deposits to banks within the United States.
Which plan is this for? (Check all that apply)
q
Tier One/Tier Two
q
Individual Account Program (IAP)
q
OPSRP Pension
q
Alternate Payee
q
Beneciary
q
P&F Units
q
Other _________________________________
Type of account (check one)
q
Checking (Attach a voided or canceled check.)
q
Savings (Do not attach a voided or canceled check.)
q
Business (Check this box if the checking or savings account is set up at your bank as a business or commercial account.)
Section B: Certication signatures (Handwritten signatures(s) required, electronic and digital signatures are not accepted.)
This authorization is to remain in full force and effect until the Oregon Public Employees Retirement System (PERS) has
received a new Domestic Authorization Agreement for Automatic Deposits form from me or written notification from me of its
termination in such time and manner as to afford PERS and the financial institution a reasonable opportunity to act on it.
*Providing your Social Security number (SSN) is voluntary. It will be used for conrmation purposes. It could also be used for the recovery of overpaid funds. If
you choose not to supply your SSN, it may take PERS sta longer to process your form.
**To comply with NACHA regulations regarding International ACH Transactions (IAT), PERS will not accept requests for electronic fund transfers (EFT) in
association with nancial institutions outside of the territorial jurisdiction of the United States. (The territorial jurisdiction the United States includes all 50
states, U.S. territories, U.S. military bases, and U.S. embassies in foreign countries.) If your entire benet will be received by or transferred to a nancial
institution outside the territorial jurisdiction of the U.S., do not submit this form, you must be paid by check.
In compliance with the Americans with Disabilities Act, PERS will provide help lling out this form upon request. You may request help by calling toll free 888-320-7377 or TTY 503-603-7766.
▶
▶
▶
Signature of joint account holder Date
Signature of payee
Date
Print joint account holder name
▶
Signature of additional joint account holder(s)
Date
Print additional joint account holder
name(s), if any
Form #459-549 (3/25/2024) SL3 IIM Code: 12315
W-4R IAP Lump Sum Withholding
Section A: Applicant information
(SSN Required. Forms without SSN will be rejected.)
11410 SW 68th Parkway, Tigard OR 97223
Mailing Address – PO Box 23700, Tigard OR 97281-3700
Toll free – 888-320-7377 Fax – 503-598-0561
Website – https://oregon.gov/pers
First name MI Last name PERS ID (optional)
Mailing address (street or PO box) Social Security number (SSN)*
City State ZIP code Country Date of birth (mm/dd/yyyy)
Home phone number Work phone number Cell phone number Personal email
In compliance with the Americans with Disabilities Act, PERS will provide help lling out this form upon request. You may request help by calling toll free 888-320-7377 or TTY 503-603-7766.
*Providing your Social Security number (SSN) is mandatory, and PERS is authorized to request it under provisions of the Internal Revenue code. It will primarily be used to comply with
mandatory IRS reporting. It could also be used for conrmation purposes or recovery of overpaid funds.
This form is strictly for IAP members who choose a one-time or 5-year distribution
Section B: Federal tax withholding
Form W-4R
Department of the Treasury
Internal Revenue Service
Withholding Certificate for Nonperiodic Payments and
Eligible Rollover Distributions
►GiveFormW-4Rtothepayerofyourretirementpayments.
0MB No. 1545-0074
202024
PERS will also withhold 8% for Oregon state tax unless you check the box in this section directing PERS not to withhold
state tax.
q
Do not withhold Oregon state income tax (8% will be withheld if box is not checked).
If you want to have more than 8% Oregon state tax withheld, check the box provided, and enter the additional amount
you want withheld on the line provided.
q
Withhold $________________.00 more than the 8% for Oregon state income tax.
Section C: Oregon tax withholding
Sign
Here
_________________________________________________________
►Your signature (This form is not valid unless you sign it.)
___________________________________________
►Date
Your withholding rate is determined by the type of payment you will receive.
● For nonperiodic payments, the default withholding rate is 10%. You can choose to have a dierent rate by
entering a rate between 0% and 100% on line 2. Generally, you can’t choose less than 10% for payments to be
delivered outside the United States and its territories.
● For an eligible rollover distribution, the default withholding rate is 20%. You can choose a rate greater
than 20% by entering the rate on line 2. You may not choose a rate less than 20%.
See page 2 for more information.
2
Complete this line if you would like a rate of withholding that is different from the default withholding
rate. See the instructions and Marginal Rate Table on page 2 for additional information. Enter the rate as
a whole number (no decimals.)
......................................................................................► 2
%
Sign
Here
_________________________________________________________
►Your signature (This form is not valid unless you sign it.)
___________________________________________
►Date
IAP Direct Transfer Rollover Acceptance
Section A: Applicant information
(Type or print clearly in dark ink. Illegible forms may be returned to applicant. This could delay your request.)
This form is strictly for the IAP. Call PERS or visit our website if this is not the form you need.
Section B: Rollover Acceptance
As an authorized representative, agent, custodian, trustee, or plan administrator of an eligible employer plan
or deferred compensation plan, I hereby accept the direct transfer rollover from the Oregon Public Employees
Retirement Systems plan, a qualified retirement plan under Internal Revenue Code 401(a), as specified below.
Choose one here: The plan
q
will
q
will not accept and separately account for after tax dollars.
Section C: Rollover account information
Rollover account number (mandatory)
Rollover plan type
Financial institution name
In compliance with the Americans with Disabilities Act, PERS will provide help filling out this form upon request. You may request help by calling toll free 888-320-7377 or TTY 503-603-7766.
Section D: Rollover mailing address and confirmation
Address
City State Zip
Fax or mail the Direct Transfer Rollover Acceptance form to:
Oregon PERS
PO Box 23700
Tigard, OR 97281-3700
Fax – 503-598-0561
Please complete and return this form immediately to avoid any delay in providing benefits.
Authorized signature (do not print)
Date
If authorized representative signature is not available, have the plan administrator authorize the acceptance of the
transfer by written confirmation. Call our Member Services toll-free 888-320-7377 if you have additional questions.
My signature below indicates acceptance of the rollover of contributions and earnings.
Section E: Authorized signature
*Providing your Social Security number (SSN) is voluntary. It will be used for confirmation purposes. If you choose not to supply your SSN, it may take PERS staff longer to process your form.
Social Security number*
First name MI Last name
PERS ID
IAP Form #459-388 (7/31/2019) SL3 IIM Code: 12157
Office use only
PERS
OPSRP
X
IAP
q Member q Alternate payee
q
Cross reference member SSN
Name and title
11410 SW 68th Parkway, Tigard OR 97223
Mailing Address – PO Box 23700, Tigard OR 97281-3700
Toll free – 888-320-7377 Fax – 503-598-0561
Website – https://oregon.gov/pers
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