Publication 570 - Tax Guide For Individuals With Income From U.s. Possessions - 2003 Page 11
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154563
Exclusion of Income for Bona Fide Residents
OMB No. 1545-0173
Form
of American Samoa
(Rev. December 1998)
Attachment
68
Attach to Form 1040.
See instructions below and on back.
Sequence No.
Department of the Treasury
Internal Revenue Service
Your social security number
Name(s) shown on Form 1040
John Black
1 1 1
0 0
1 1 1 1
Part I
General Information
6-2-02
not ended
1
Date bona fide residence began
and ended
,
X
Rented room
Rented house or apartment
2
Type of living quarters in
American Samoa
Quarters furnished by employer
Purchased home
X
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?
X
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.
Samoa Products Co , Pago Pago , American Samoa
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
11-11-03
11-25-03
14
Vacation to New Zealand
Part II
Figure Your Exclusion. Include only income that qualifies for the exclusion. See instructions.
24,000
7
7
Wages, salaries, tips, etc.
8
8
Taxable interest
320
9
9
Ordinary dividends
10
10
Business income
11
11
Capital gain
12
12
Rental real estate, royalties, etc.
13
13
Farm income
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
24,320
15
Instructions
entered into an implementation agreement. Also, the effective
date of the agreement between the United States and Guam
Section references are to the Internal Revenue Code.
had not been determined.
Purpose of Form
Bona Fide Residence Test
If you qualify, use Form 4563 to figure the amount of income
To qualify under this test, you must be a bona fide resident
you may exclude from your gross income.
of American Samoa for an uninterrupted period that includes
a complete tax year (January 1–December 31 if you file a
Who Qualifies
calendar year return).
You qualify for the exclusion if you were a bona fide resident
No specific rule determines if you are a bona fide resident
of American Samoa for the entire tax year. See Bona Fide
of American Samoa. At the time this form went to print,
Residence Test on this page.
regulations defining the bona fide residence test under
section 931 had not been published. The following factors
In future years, bona fide residents of Guam and
may be considered:
the Commonwealth of the Northern Mariana
● Intent,
Islands ( CNMI) may also qualify for the exclusion.
They will not qualify, however, unless
● Establishment of a permanent home,
implementation agreements are in effect with the United
● Assimilation into the social, cultural, and economic
States. At the time this form went to print, the CNMI had not
environment, and
4563
For Paperwork Reduction Act Notice, see back of form.
Cat. No. 12909U
Form
(Rev. 12-98)
Page 11
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