Publication 54 - Tax Guide For U.s. Citizens And Resident Aliens Abord - 2011 Page 28
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442555-EZ
OMB No. 1545-0074
Foreign Earned Income Exclusion
Form
2011
Department of the Treasury
Attachment
See separate instructions.
Attach to Form 1040.
34A
(99)
▶
▶
Internal Revenue Service
Sequence No.
Your social security number
Name shown on Form 1040
Judith E. Adams
222-00-2222
• Are a U.S. citizen or a resident alien.
• Do not have self-employment income.
You May Use
• Earned wages/salaries in a foreign country.
• Do not have business/moving expenses.
This Form
And You:
• Had total foreign earned income
• Do not claim the foreign housing
If You:
of $92,900 or less.
exclusion or deduction.
• Are ling a calendar year return that covers
a 12-month period.
Tests To See If You Can Take the Foreign Earned Income Exclusion
Part I
1
Bona Fide Residence Test
a
Were you a bona de resident of a foreign country or countries for a period that includes an entire tax year
(see page 2 of the instructions)?
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Yes
No
• If you answered “Yes,” you meet this test. Fill in line 1b and then go to line 3.
• If you answered “No,” you do not meet this test. Go to line 2 to see if you meet the Physical Presence Test.
b Enter the date your bona de residence began
, and ended (see instructions)
.
▶
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2
Physical Presence Test
a
Were you physically present in a foreign country or countries for at least 330 full days during—
{
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Yes
No
2011 or
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any other period of 12 months in a row starting or ending in 2011?
• If you answered “Yes,” you meet this test. Fill in line 2b and then go to line 3.
• If you answered “No,” you do not meet this test. You cannot take the exclusion unless you meet the
Bona Fide Residence Test above.
1-1-11
12-31-11
b The physical presence test is based on the 12-month period from
through
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3
Tax Home Test. Was your tax home in a foreign country or countries throughout your period of bona de
residence or physical presence, whichever applies? .
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Yes
No
• If you answered “Yes,” you can take the exclusion. Complete Part II below and then go to page 2.
• If you answered “No,” you cannot take the exclusion. Do not le this form.
General Information
Part II
4 Your foreign address (including country)
5 Your occupation
21 Rue Reynaud
City Y, Country Y
Secretary
6 Employer’s name
7 Employer’s U.S. address (including ZIP code) 8 Employer’s foreign address
2645 Pewter Place
40 Rue Royale
Anytown, Anystate, U.S.A.
City Y, Country Y
A B Insurance Co., Inc.
Employer is (check any that apply):
9
A U.S. business .
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a
b A foreign business .
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Other (specify)
c
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If you led Form 2555 or 2555-EZ after 1981, enter the last year you led the form.
2010
10 a
▶
b If you did not le Form 2555 or 2555-EZ after 1981, check here
and go to line 11a now.
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Have you ever revoked the foreign earned income exclusion?
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Yes
No
c
d If you answered “Yes,” enter the tax year for which the revocation was effective.
▶
City Y, Country Y 6-1-2008
List your tax home(s) during 2011 and date(s) established.
11a
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b Of what country are you a citizen/national?
United States
▶
2555-EZ
For Paperwork Reduction Act Notice, see the Form 1040 instructions.
Form
(2011)
Cat. No. 13272W
Chapter 4 Foreign Earned Income and Housing: Exclusion – Deduction
Page 28
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