Exclusion of Income for Bona Fide Residents OMB No. 1545-0074

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 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

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 unless

otherwise noted.

(Rev. December 2008)

Part I

Part II

General Information

b

b

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

● From sources within American Samoa, or

For Paperwork Reduction Act Notice, see back of form. Cat. No. 12909U Form 4563 (Rev. 12-2008)

What’s new. For tax years ending after April 9, 2008 (or

beginning with tax year 2008 if a calendar year taxpayer), you

may exclude amounts paid to you for services you performed

as an employee of the American Samoa government or any

of its agencies.

Reminder. 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 details, see the Instructions for

Form 8898.

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:

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

income from American Samoa you may exclude from your

gross income.

● Effectively connected with the conduct of a trade or

business in American Samoa.

Where to file. File your Form 1040 (including Form 4563)

with the Department of the Treasury, Internal Revenue

Service Center, Austin, TX 73301-0215.

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.

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.
Form 4563 (Rev. 12-2008) Page 2

Filing Form 1040

Part II—Figure Your Exclusion

To exclude your qualifying income from American Samoa,

complete Form 4563 and attach it to your Form 1040.

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, below.

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.

● 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.

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.

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.

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.

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 chapter 2 of Pub. 570, Regulations

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

1.937-2(k).

CAUTION

Source of income. The rules for determining the source of

income are explained in sections 861 through 865, section

937, in Regulations section 1.937-2, and in 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.

● 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.

● Taxable refunds, credits, or offsets of local American

Samoan income taxes include only nonmirror code income

taxes.

● Alimony received from a person who is a bona fide

resident of American Samoa is sourced in American Samoa.

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.

Deduction 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, 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 may 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.

Penalty for Failure To Furnish Information

If you fail to provide the required information, you may have

to pay a $1,000 penalty 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.

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.

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.

CAUTION

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 may exclude the earnings from

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

any self-employment tax due.

Additional information. Pub. 570 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.

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

disposition of real property (and interest in real property) are

generally sourced where the real property is located.