General Information

OMB No. 1545-1326

Foreign Earned Income Exclusion Form 2555-EZ

Department of the Treasury

Internal Revenue Service © See separate instructions. © Attach to Form 1040.

Name shown on Form 1040 Your social security number

Your foreign address (including country) Your occupation

Employer’s name

For Paperwork Reduction Act Notice, see page 1 of separate instructions. Cat. No. 13272W Form 2555-EZ (1995)

4 5

6

9 Employer is (check any that apply):

A U.S. business

A foreign business

Other (specify) ©

10a

If you answered “Yes,” enter the tax year for which the revocation was effective. ©

b Of what country are you a citizen/national? ©

Have you ever revoked the foreign earned income exclusion? Yes No

7 Employer’s U.S. address (including ZIP code) 8 Employer’s foreign address

● Are a U.S. citizen or a resident alien.

● Earned wages/salaries in a foreign country.

● Had total foreign earned income of

$70,000 or less.

● Do not have self-employment income.

● Do not have business/moving expenses. And You:

You May Use

This Form

If You:

b

c

a

b

c

● Do not claim the foreign housing

exclusion or deduction.

Part II

● Are filing a calendar year return that

covers a 12-month period.

11a List your tax home(s) during 1995 and date(s) established. ©

If you filed Form 2555 or 2555-EZ after 1981, enter the last year you filed the form. ©

If you did not file Form 2555 or 2555-EZ after 1981, check here © and go to line 11a now.

d

1 Bona Fide Residence Test

Yes No

Enter the date your bona fide residence began © , and ended (see instructions) © .

2 Physical Presence Test

Yes No

b

a

b

a

Tests To See If You Can Take the Foreign Earned Income Exclusion

Were you a bona fide resident of a foreign country or countries for a period that includes an entire tax year

(see page 2 of the instructions)?

Were you physically present in a foreign country or countries for at least 330 full days during—

● 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.

1995, or

any other period of 12 months in a row starting or ending in 1995?

● 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.

The physical presence test is based on the 12-month period from © 

● If you answered “No,” you cannot take the exclusion. Do not file this form.

Tax Home Test. Was your tax home in a foreign country or countries throughout your period of bona fide

residence or physical presence, whichever applies?

$ %

through © .

3

Yes No

● If you answered “Yes,” you can take the exclusion. Complete Part II below and then go to page 2.

Part I

Attachment

Sequence No. 34A
Form 2555-EZ (1995) Page 2

$70,000 00

Enter the number of days in your qualifying period that fall within 1995

● If you entered 365 days on line 14, enter “1.00” here.

Multiply line 13 by line 15

3 .

Enter, in U.S. dollars, the total foreign earned income you earned and received in 1995 (see

instructions). Be sure to include this amount on Form 1040, line 7

Foreign earned income exclusion. Enter the smaller of line 16 or line 17 here and in

parentheses on Form 1040, line 21. Next to the amount write “2555-EZ.” On Form 1040, subtract

this amount from your income to arrive at total income on Form 1040, line 22 ©

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13

14

15

16

17

Maximum foreign earned income exclusion 13

14

15

17

18

16

Part IV Figure Your Foreign Earned Income Exclusion

● Otherwise, divide line 14 by 365 and enter the result here as a decimal (to two places).%

Part III

(d) Income earned in U.S. 

on business (attach computation)

(c) Number of days

in U.S. on business (a) Date arrived in U.S. (b) Date left U.S.

Days Present in the United States—Complete this part if you were present in

the United States or its possessions in 1995.

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