om 4963

Department of the Treasury
Internal Revenue Service

Exclusion of Income for Bona Fide Residents
of American Samoa

» See instructions below and on back.
> Attach to Form 1040.

OMB No, 1545-0173

7990

Attachment
Sequence No. 6!

Name(s) shown on Form 1040

Your social security number

A Date bona fide residence began _
B_ Kind of living quarters in >
American Samoa

O Rented room

© Quarters furnished by employer

C Did any of your family live with you in American Samoa during any part of the tax year?
If “Yes,” who and for what period? >__

CO Rented house or apartment
Cl Purchased home

D Did you maintain any home(s) outside of American Samoa? .
if “Yes,”

show address of your home(s), whether it was rented, and the names and ‘relationships of the occupants >

F Complete the following for days absent from American Samoa during 1990.

Date of
departure

Date of
return

Number of days
absent

Reason for absence

Include on lines 1 through 8 below only income that qualifies for the exclusion. (See the instructions.)

Wages, salaries, tips, etc. .

Taxable interestincome . . . .
Dividend income .

Rent and royalty income

Business income .

Farmincome .

Capital gains .

Other income (list type and amount) la

ONaAnNawWrHH

©

1990 gross income _.

Add the amounts on lines 1 through 8 and enter the total. This is the amount you may exclude from your

Ia fon for | foo [no Je

joo

9

Instructions
(Section references are to the Internal Revenue Code.)

Paperwork Reduction Act Notice
We ask for the information on this form to carry out the Internal
Revenue laws of the United States. You are required to give us this
information, We need it to ensure that you are complying with these
laws and to allow us to figure and collect the right amount of tax.
The time needed to complete and file this form will vary
depending on individual circumstances. The estimated average
time is:

Recordkeeping .. . soe 33 min,
Learning about the law or the form. » Smin.
Preparing the form . . 25 min.
Copying, assembling, and sending

theformtoIRS . 6... 1 we sone es 17 min.

If you have comments concerning the accuracy of these time
estimates or suggestions for making this form more simple, we

would be happy to hear from you. You can write to both the IRS and
the Office of Management and Budget at the addresses listed in the
Instructions for Form 1040.

Purpose

If you qualify, use Form 4563 to figure the amount of income you
can exclude.

Who Qualifies

You qualify for the exclusion if you were a bona fide resident of
American Samoa during all of 1990 (see Bona Fide Residence Test
on page 2).

Note: Bona fide residents of Guam will qualify for the exclusion
effective January 1, 1991. In future years, bona fide residents of the
Commonwealth of the Northern Mariana Islands (CNMI) may also
qualify for the exclusion. They will not qualify, however, unless an
implementation agreement is in effect between the CNMI and the
United States, At the time this form went to print, the CNMI had not
entered into an implementation agreement.

Form 4563 (1990)


Form 4563 (1990)

Page 2

Bona Fide Residence Test.—To qualify under this test you must
be a bona fide resident of American Samoa for an uninterrupted
period that includes a complete tax year (January 1-December 31,
if you file a calendar year return).

No specific rule determines whether you are a bona fide resident
of American Samoa. At the time this form went to print, regulations
were being written defining the bona fide residence test under
section 931. The following factors may be considered:

@ Intent;
e Establishment of a permanent home;

e Assimilation into the social, cultural, and economic environment;
and
@ Physical presence.

Other factors that may be considered are the nature, extent and
reasons for temporary absences; assumption of economic burdens
and payment of taxes to American Samoa; existence of other
homes outside American Samoa; and place of employment.

What Income Can Be Excluded

If you qualify, you can exclude the following:

© Income received from sources in American Samoa, Guam, and
the CNMI; and

@ Income effectively connected with the conduct of a trade or
business in those possessions.

Get Pub. 570, Tax Guide for Individuals With Income From U.S.
Possessions, for information on how to determine the source of
income.

Employees of the United States.—Amounts paid to you for
services you performed as an employee of the U.S. Government or
any of its agencies cannot be excluded. This rule applies to both
civilian and military employees.

Income You Must Report on Form 1040

Even if you qualify for the exclusion, you must still report on Form
1040 your worldwide income (less the exclusion allowed by this
form). This includes all income you received during 1990 that does
not qualify for the exclusion. The source of that income does not
matter

Deductions and Credits You May Not Take
on Form 1040

If you claim the exclusion, you may not take any deduction or credit
on Form 1040 that is definitely related to the excluded income.

Deductions and credits that are not definitely related to any
particular type of income must be allocated between your
excludable income and your other income to find the amount you
may take on Form 1040. Examples of deductions that are not
definitely related to any particular type of income are the standard
deduction and certain itemized deductions (such as medical
expenses, charitable contributions, and real estate taxes and
mortgage interest on your personal residence).

For more information, including how to figure the amount
allocable to the excluded income, see Pub. 570.

Note: You can take a deduction for each exemption you are
entitled to claim. This deduction is not considered allocable to the
excluded income.

Self-Employed Individuals

If you were self-employed and your net earnings from self-
employment were $400 or more, you will generally have to pay
self-employment tax on those earnings even though you can
exclude them from your gross income. Use Schedule SE (Form
1040) to figure any self-employment tax due.

Where To File

Mail your return to the Internal Revenue Service Center,
Philadelphia, PA 19255, U.S.A.

Note: /f you do not qualify for the exclusion, follow the Instructions
for Form 1040. Report all your taxable income, including income
from U.S., foreign, and possession sources. File your return with
the Internal Revenue Service Center shown in the Form 1040
Instructions for the place where you live.