Form 4563 - Exclusion Of Income For Bona Fide Residents Of American Samoa
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1
24563
Exclusion of Income for Bona Fide Residents
OMB No. 1545-0173
Form
of American Samoa
(Rev. October 1996)
Attachment
68
Attach to Form 1040.
See instructions below and on back.
Sequence No.
Department of the Treasury
Internal Revenue Service
Name(s) shown on Form 1040
Your social security number
Part I
General Information
1
Date bona fide residence began
and ended
,
Rented room
Rented house or apartment
2
Type of living quarters in
Quarters furnished by employer
Purchased home
American Samoa
3a Did any of your family live with you in American Samoa during any part of the tax year?
Yes
No
b
If “Yes,” who and for what period?
4a Did you maintain any home(s) outside American Samoa?
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.
5
Name and address of employer (state if self-employed)
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.
7
7
Wages, salaries, tips, etc.
8
8
Taxable interest income
9
9
Dividend income
10
10
Rent and royalty income
11
11
Business income
12
12
Farm income
13
13
Capital gains
14
Other income. List type and amount
14
15
Add lines 7 through 14. This is the amount you may exclude from your gross income this tax
year
15
Instructions
The time needed to complete and file this form will vary
depending on individual circumstances. The estimated
Section references are to the Internal Revenue Code.
average time is:
Recordkeeping
33 min.
Paperwork Reduction Act Notice
Learning about the law or the form
7 min.
We ask for the information on this form to carry out the
Preparing the form
25 min.
Internal Revenue laws of the United States. You are required
to give us the information. We need it to ensure that you are
Copying, assembling, and sending
complying with these laws and to allow us to figure and
the form to the IRS
17 min.
collect the right amount of tax.
If you have comments concerning the accuracy of these
time estimates or suggestions for making this form simpler,
You are not required to provide the information requested
on a form that is subject to the Paperwork Reduction Act
we would be happy to hear from you. You can write or call
unless the form displays a valid OMB control number. Books
the IRS. See the Instructions for Form 1040.
or records relating to a form or its instructions must be
Purpose of Form
retained as long as their contents may become material in
the administration of any Internal Revenue law. Generally, tax
If you qualify, use Form 4563 to figure the amount of income
returns and return information are confidential, as required by
you may exclude from your gross income.
section 6103.
4563
Cat. No. 12909U
Form
(Rev. 10-96)
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