Exclusion of Income for Bona Fide Residents OMB No. 1545-0173

of American Samoa Form 4563

Department of the Treasury © See instructions below and on back.

Internal Revenue Service

Attachment

© Attach to Form 1040. Sequence No. 68

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

1 Date bona fide residence began © , and ended ©

2 Type of living quarters in Rented room Rented house or apartment

American Samoa © Quarters furnished by employer Purchased home

3a Did any of your family live with you in American Samoa during any part of the tax year? Yes No

If “Yes,” who and for what period? ©

4a Did you maintain any home(s) outside American Samoa? Yes No

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.

(c) Number of

days absent

(b) Date

returned (a) Date left (d) Reason for absence

7 Wages, salaries, tips, etc. 7

8 Taxable interest income 8

9 Dividend income 9

10 Rent and royalty income 10

11 Business income 11

12 Farm income 12

13 Capital gains 13

14 Other income. List type and amount ©

14

Add lines 7 through 14. This is the amount you may exclude from your gross income this tax

year ©

15

15

Instructions

Section references are to the Internal Revenue Code.

Paperwork Reduction Act Notice

Purpose of Form

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.

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

you may exclude from your gross income.

The time needed to complete and file this form will vary

depending on individual circumstances. The estimated

average time is:

Recordkeeping 33 min.

Learning about the law or the form 7 min.

Preparing the form 25 min.

Copying, assembling, and sending

the form to the IRS 17 min.

If you have comments concerning the accuracy of these

time estimates or suggestions for making this form simpler,

we would be happy to hear from you. You can write or call

the IRS. See the Instructions for Form 1040.

Cat. No. 12909U Form 4563 (Rev. 10-96)

(Rev. October 1996)

Part I

Part II

General Information

b

b

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

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.
Form 4563 (Rev. 10-96) Page 2

Bona Fide Residence Test

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.

No specific rule determines if you are a bona fide resident

of American Samoa. At the time this form went to print,

regulations defining the bona fide residence test under

section 931 had not been published. The following factors

may be considered:

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:

● Intent,

● Establishment of a permanent home,

● Assimilation into the social, cultural, and economic

environment, and

For more details, including how to figure the amount

allocable to the excluded income, see Pub. 570.

● 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.

Note: Generally, you may take a deduction for each

exemption you are entitled to claim. This deduction is not

considered allocable to the excluded income.

Self-Employed Individuals

What Income May Be Excluded

If you were self-employed and your net earnings from selfemployment were $400 or more, you will generally have to

pay self-employment tax on those earnings even though you

may exclude them from your gross income. Use Schedule

SE (Form 1040) to figure any self-employment tax due.

If you qualify, you may 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.

Where To File

For details on how to determine the source of income, see

Pub. 570, Tax Guide for Individuals With Income From U.S.

Possessions.

Mail your return to the Internal Revenue Service Center,

Philadelphia, PA 19255-0002, U.S.A.

Employees of the United States

Note: If 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.

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.

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).

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 rule applies to both civilian and military

employees.

● 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.

Who Qualifies

You qualify for the exclusion if you were a bona fide resident

of American Samoa for the entire tax year. See Bona Fide

Residence Test below.

Note: In future years, bona fide residents of Guam and the

Commonwealth of the Northern Mariana Islands ( CNMI) may

also qualify for the exclusion. They will not qualify, however,

unless implementation agreements are in effect with the

United States. At the time this form went to print, the CNMI

had not entered into an implementation agreement. Also, the

effective date of the agreement between the United States

and Guam had not been determined.