Form 4563 

(Rev. December 2011) 

Department of the Treasury 

Internal Revenue Service 

Exclusion of Income for Bona Fide Residents 

of American Samoa 

▶ Attach to Form 1040. ▶ See instructions below and on back. 

OMB No. 1545-0074

Attachment 

Sequence No. 68

Name(s) shown on Form 1040 Your social security number

Part I General Information

1 Date bona fide residence began ▶ , and ended ▶

2 Type of living quarters in 

American Samoa

▲

Rented room Rented house or apartment

Quarters furnished by employer Purchased home

3 a 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? ▶

4 a 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. ▶

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. 

(a) Date left (b) Date

returned 

(c) Number of

days absent (d) Reason for absence 

Part II Figure Your Exclusion. Include only income that qualifies for the exclusion. See instructions. 

7 Wages, salaries, tips, etc . . . . . . . . . . . . . . . . . . . . . . . . . 7 

8 Taxable interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 

9 Ordinary dividends . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 

10 Business income . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 

11 Capital gain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 

12 Rental real estate, royalties, etc. . . . . . . . . . . . . . . . . . . . . . . 12 

13 Farm income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 

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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ▶ 15 

Section references are to the Internal Revenue Code unless 

otherwise noted. 

Instructions 

Purpose of form. Use Form 4563 to figure the amount of 

income from American Samoa you may exclude from your 

gross income. 

Who qualifies. You generally qualify for the exclusion if you 

were a bona fide resident of American Samoa for the entire tax 

year and your income was:

• From sources within American Samoa, or 

• Effectively connected with the conduct of a trade or business 

in American Samoa. 

Employees of the United States. You may not exclude

amounts paid to you for services you performed as an employee 

of the U.S. government or any of its agencies. This applies to 

both civilian and military employees, but does not include 

employees of the American Samoa government. 

Where to file. If you are not enclosing a check or money order, 

file your Form 1040 (including Form 4563) with the Department 

of the Treasury, Internal Revenue Service Center, Austin, TX 

73301-0215 USA.

If you are including a check or money order, file your return 

with the Internal Revenue Service, P.O. Box 1303, Charlotte, NC 

28201-1303 USA. 

Note. If you do not qualify for the exclusion, follow the 

instructions for Form 1040 or 1040A. Report all your taxable 

income, including income from U.S., foreign, and possession 

sources. Send your return to the address shown in the Form 

1040 instructions. 

Additional information. Pub. 570, Tax Guide for Individuals 

With Income From U.S. Possessions, has more information and 

an example of how to complete Form 4563. To get Pub. 570, 

see Quick and Easy Access to Tax Help and Forms in the 

Instructions for Form 1040. 

Part II—Figure Your Exclusion 

On lines 7 through 14 include only income that is from sources 

within American Samoa or effectively connected with the 

conduct of a trade or business in American Samoa. For details 

on how to determine the source of income, see Source of 

income, later. 

For Paperwork Reduction Act Notice, see Form 1040 instructions. Cat. No. 12909U Form 4563 (Rev. 12-2011) 
Form 4563 (Rev. 12-2011) Page 2 

Source of income. The rules for determining the source of 

income are explained in sections 861 through 865 and section

937, Regulations section 1.937-2, and chapter 2 of Pub. 570. 

Some general rules are: 

• The source of wages, salaries, or tips is generally where the 

services are performed. If you worked both in and outside 

American Samoa, include on line 7 only wages, salaries, or tips 

earned while you were in American Samoa. 

Military spouses. If you are the civilian spouse of a member 

of the U.S. Armed Forces, work in American Samoa, and retain 

a residence or domicile in one of the 50 states or the District of 

Columbia under the Military Spouses Residency Relief Act 

(MSRRA), your wages, salaries, tips, and self-employment 

income will not be considered income from American Samoa. 

Under MSRRA, the military spouse must be in American Samoa 

solely to be with his/her service member spouse who is serving 

in compliance with military orders. MSRRA applies to qualified 

individuals for the 2009 calendar year or subsequent years. For 

details on MSRRA, see Pub. 570.

• The source of interest income is generally where the payer is 

located. For example, American Samoan source income 

includes interest from a certificate of deposit issued by a bank 

or branch of a U.S. bank in American Samoa. 

• Generally, dividends are sourced where the paying 

corporation is created or organized. 

• Alimony received from a person who is a bona fide resident of 

American Samoa is sourced in American Samoa. 

• Except as provided in regulations, income earned after 

December 31, 2004, that is from sources within the United 

States or effectively connected with the conduct of a trade or 

business in the United States is not income from American 

Samoa. 

• The source of gains, profits, or income from the sale or 

disposition of real property (and any interest in real property) is 

generally where the real property is located. 

Personal property. The source of income from the sale of 

nondepreciable personal property is generally the seller’s 

residence. For example, if you are a bona fide resident of 

American Samoa, gain from the sale or disposition of personal 

property is generally from sources within American Samoa. 

Income from the sale of inventory is generally sourced where 

the title to the property passes. See section 865 for details. 

De minimis exception. This is an exception to the general 

rule for determining the source of income earned in American 

Samoa. Generally, income from American Samoa does not 

include compensation for services performed in American 

Samoa if during 2011 you:

• Were a U.S. citizen or resident,

• Were not a bona fide resident of American Samoa,

• Were not employed by or under contract with an individual, 

partnership, or corporation that is engaged in a trade or 

business in American Samoa,

• Temporarily performed services in American Samoa for 90 

days or less, and 

• Earned $3,000 or less from such services.

▲!

CAUTION

Special rules may apply to bona fide residents of U.S. 

possessions who have gain from dispositions of 

certain investment property within the 10-year period 

beginning when they became a bona fide resident. 

For details, see Special Rules for Gains From Dispositions of

Certain Property, in chapter 2 of Pub. 570, Regulations section 

1.937-2(f)(1), and Examples 1 and 2 of section 1.937-2(k). 

Filing Form 1040 

To exclude your qualifying income from American Samoa, 

complete Form 4563 and attach it to your Form 1040. 

Income you must report on Form 1040. You must report on 

Form 1040 your worldwide income for the tax year that does not 

qualify for the exclusion. The source of that income does not 

matter. 

Deduction and credits you cannot take on Form 1040. If you 

claim the exclusion, you cannot take any deduction or credit on 

Form 1040 that is definitely related to the excluded income, 

such as employee business expenses. 

Deductions and credits that are not definitely related to a 

particular type of income must be allocated between your 

excluded income and your other income to find the amount you 

can take on Form 1040. Examples of deductions that are not 

definitely related to a particular type of income are: 

• The standard deduction, and 

• Certain itemized deductions such as medical and dental 

expenses, gifts to charity, and real estate taxes and mortgage 

interest on your personal residence. 

For more details, including how to figure the amount allocable 

to the excluded income, see chapter 4 of Pub. 570. 

Note. Generally, you can take a deduction for each 

exemption you are entitled to claim. This deduction is not 

considered allocable to the excluded income. 

▲!

CAUTION

If you were a bona fide resident of American Samoa 

for the entire tax year, or were considered a bona fide 

resident of American Samoa for the entire tax year 

under the special rules for the year of a move (see 

Pub. 570, chapter 1), but not a U.S. citizen or resident, certain 

credits and deductions may not be available to you. See 

Nonresident alien under Bona Fide Resident of American Samoa 

in Pub. 570, chapter 3, for specific information. 

Self-employed individuals. If you were self-employed and 

your net earnings from self-employment were $400 or more, 

generally you will have to pay self-employment tax on those 

earnings even though you can exclude the earnings from your 

gross income. Use Schedule SE (Form 1040) to figure any 

self-employment tax due. 

Penalty for Failure To Furnish Information 

If, in tax year 2001 or later, you became or ceased to be a bona 

fide resident of a U.S. possession, you may be required to file 

Form 8898, Statement for Individuals Who Begin or End Bona 

Fide Residence in a U.S. Possession. The penalty for failure to 

provide the required information is $1,000 for each failure unless 

you can show the failure was due to reasonable cause and not 

willful neglect. This penalty is in addition to any criminal penalty 

provided by law. For details, see the Instructions for Form 8898. 

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 the 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. 

You are not required to provide the information requested on 

a form that is subject to the Paperwork Reduction Act unless 

the form displays a valid OMB control number. Books or 

records relating to a form or its instructions must be retained as 

long as their contents may become material in the 

administration of any Internal Revenue law. Generally, tax 

returns and return information are confidential, as required by 

section 6103. 

The average time and expenses required to complete and file 

this form will vary depending on individual circumstances. For 

the estimated averages, see the instructions for your income tax 

return. 

If you have suggestions for making this form simpler, we 

would be happy to hear from you. See the instructions for your 

income tax return.