Part 96, page 22

Transcript

The scan is the source; the transcript is machine-generated from it.

Form W-4 (Rev. Aug. 1972) Department of the Treasury Internal Revenue Service

Employee's Withholding Allowance Certificate (This certificate is for income tax withholding purposes only; it will remain in effect until you change it.)

Type or print your full name: MACK A. PASTERBROOK

Your social security number: 557-46-8529

Home address (Number and street or rural route): [guess: P.O.] Box 950 BEAVERTON

Marital status: ☐ Single ☒ Married (if married but legally separated, or wife (husband) is a nonresident alien, check the single block.)

City or town, State and ZIP code: BEAVERTON OR [guess: 09065]

1 Total number of allowances you are claiming . . . . . . . . . . . . . . . 4

2 Additional amount, if any, you want deducted from each pay (if your employer agrees) $ 0

I certify that to the best of my knowledge and belief, the number of withholding allowances claimed on this certificate does not exceed the number to which I am entitled.

Signature ▶ [guess: Mack] A. [guess: Pasterbrook] Date ▶ 11/20/73

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DB Cooper-42920