Form 2555 - Foreign Earned Income - 2012
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32555
OMB No. 1545-0074
Foreign Earned Income
2012
Form
Attach to Form 1040.
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Department of the Treasury
Attachment
34
Information about Form 2555 and its separate instructions is at
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Sequence No.
Internal Revenue Service
For Use by U.S. Citizens and Resident Aliens Only
Your social security number
Name shown on Form 1040
General Information
Part I
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2
Your foreign address (including country)
Your occupation
Employer’s name
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4 a Employer’s U.S. address
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b Employer’s foreign address
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a
b
c
A foreign entity
A U.S. company
Self
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Employer is (check
d
e
any that apply):
A foreign affiliate of a U.S. company
Other (specify)
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6 a If you previously filed Form 2555 or Form 2555-EZ, enter the last year you filed the form.
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b If you did not previously file Form 2555 or 2555-EZ to claim either of the exclusions, check here
and go to line 7.
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c Have you ever revoked either of the exclusions? .
Yes
No
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d If you answered “Yes,” enter the type of exclusion and the tax year for which the revocation was effective.
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Of what country are you a citizen/national?
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8 a Did you maintain a separate foreign residence for your family because of adverse living conditions at your
tax home? See Second foreign household in the instructions
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Yes
No
b If “Yes,” enter city and country of the separate foreign residence. Also, enter the number of days during your tax year that you
maintained a second household at that address.
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List your tax home(s) during your tax year and date(s) established.
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Next, complete either Part II or Part III. If an item does not apply, enter “NA.” If you do not give
the information asked for, any exclusion or deduction you claim may be disallowed.
Taxpayers Qualifying Under Bona Fide Residence Test (see instructions)
Part II
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Date bona fide residence began
, and ended
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11
Kind of living quarters in foreign country
a
Purchased house
b
Rented house or apartment
c
Rented room
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d
Quarters furnished by employer
12a Did any of your family live with you abroad 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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13 a Have you submitted a statement to the authorities of the foreign country where you claim bona fide
Yes
No
residence that you are not a resident of that country? See instructions
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b Are you required to pay income tax to the country where you claim bona fide residence? See instructions .
Yes
No
If you answered “Yes” to 13a and “No” to 13b, you do not qualify as a bona fide resident. Do not complete the rest of
this part.
If you were present in the United States or its possessions during the tax year, complete columns (a)–(d) below. Do not
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include the income from column (d) in Part IV, but report it on Form 1040.
(c) Number of
(d) Income earned in
(c) Number of
(d) Income earned in
(a) Date
(b) Date left
(a) Date
(b) Date left
days in U.S.
U.S. on business
days in U.S. on
U.S. on business
arrived in U.S.
U.S.
arrived in U.S.
U.S.
on business
(attach computation)
business
(attach computation)
15a List any contractual terms or other conditions relating to the length of your employment abroad.
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b Enter the type of visa under which you entered the foreign country.
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c Did your visa limit the length of your stay or employment in a foreign country? If “Yes,” attach explanation .
Yes
No
d Did you maintain a home in the United States while living abroad? .
Yes
No
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e If “Yes,” enter address of your home, whether it was rented, the names of the occupants, and their relationship
to you.
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2555
For Paperwork Reduction Act Notice, see the Form 1040 instructions.
Form
(2012)
Cat. No. 11900P
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