Form 4563 (Rev. December 2011) - Exclusion Of Income For Bona Fide Residents Of American Samoa
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14563
Exclusion of Income for Bona Fide Residents
OMB No. 1545-0074
Form
of American Samoa
(Rev. December 2011)
Attachment
68
Attach to Form 1040.
See instructions below and on back.
Department of the Treasury
Sequence No.
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Internal Revenue Service
Your social security number
Name(s) shown on Form 1040
Part I
General Information
1
Date bona fide residence began
, and ended
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Rented room
Rented house or apartment
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Type of living quarters in
American Samoa
Quarters furnished by employer
Purchased home
3 a Did any of your family live with you in American Samoa during any part of the tax year? .
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Yes
No
b If “Yes,” who and for what period?
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4 a Did you maintain any home(s) outside American Samoa? .
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Yes
No
b If “Yes,” show address of your home(s), whether it was rented, the name of each occupant, and his or her relationship to
you.
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Name and address of employer (state if self-employed)
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6
Complete columns (a) through (d) below for days absent from American Samoa during the tax year.
(b) Date
(c) Number of
(a) Date left
(d) Reason for absence
returned
days absent
Part II
Figure Your Exclusion. Include only income that qualifies for the exclusion. See instructions.
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Wages, salaries, tips, etc .
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Taxable interest .
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Ordinary dividends .
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Business income
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Capital gain .
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Rental real estate, royalties, etc.
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Farm income .
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Other income. List type and amount
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Add lines 7 through 14. This is the amount you may exclude from your gross income this tax
year .
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Section references are to the Internal Revenue Code unless
of the Treasury, Internal Revenue Service Center, Austin, TX
otherwise noted.
73301-0215 USA.
If you are including a check or money order, file your return
Instructions
with the Internal Revenue Service, P.O. Box 1303, Charlotte, NC
28201-1303 USA.
Purpose of form. Use Form 4563 to figure the amount of
income from American Samoa you may exclude from your
Note. If you do not qualify for the exclusion, follow the
gross income.
instructions for Form 1040 or 1040A. Report all your taxable
income, including income from U.S., foreign, and possession
Who qualifies. You generally qualify for the exclusion if you
sources. Send your return to the address shown in the Form
were a bona fide resident of American Samoa for the entire tax
1040 instructions.
year and your income was:
Additional information. Pub. 570, Tax Guide for Individuals
• From sources within American Samoa, or
With Income From U.S. Possessions, has more information and
• Effectively connected with the conduct of a trade or business
an example of how to complete Form 4563. To get Pub. 570,
in American Samoa.
see Quick and Easy Access to Tax Help and Forms in the
Employees of the United States. You may not exclude
Instructions for Form 1040.
amounts paid to you for services you performed as an employee
Part II—Figure Your Exclusion
of the U.S. government or any of its agencies. This applies to
both civilian and military employees, but does not include
On lines 7 through 14 include only income that is from sources
employees of the American Samoa government.
within American Samoa or effectively connected with the
Where to file. If you are not enclosing a check or money order,
conduct of a trade or business in American Samoa. For details
file your Form 1040 (including Form 4563) with the Department
on how to determine the source of income, see Source of
income, later.
4563
For Paperwork Reduction Act Notice, see Form 1040 instructions.
Form
(Rev. 12-2011)
Cat. No. 12909U
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