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

of American Samoa Form 4563

© See Instructions below and on back.

Department of the Treasury

Internal Revenue Service

Attachment

© Attach to Form 1040. Sequence No. 68

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

A Date bona fide residence began , ended .

B Kind of living quarters in Rented room Rented house or apartment

American Samoa © Quarters furnished by employer Purchased home

C 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? ©

D Did you maintain any home(s) outside of American Samoa? Yes No

If “Yes,” show address of your home(s), whether it was rented, and the names and relationships of the occupants ©

E Name and address of employer (state if self-employed) ©

F Complete the following for days absent from American Samoa during 1991.

Number of

days absent

Date of

return

Date of

departure Reason for absence

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

1 Wages, salaries, tips, etc. 1

2 Taxable interest income 2

3 Dividend income 3

4 Rent and royalty income 4

5 Business income 5

6 Farm income 6

7 Capital gains 7

8 Other income (list type and amount) ©

8

Add lines 1 through 8 and enter the total. This is the amount you may exclude from your 1991

gross income ©

9

9

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.

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 can exclude from your gross income.

Who Qualifies

The time needed to complete and file this form will vary

depending on individual circumstances. The estimated

average time is:

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

of American Samoa during all of 1991 (see Bona Fide

Residence Test on page 2).

Recordkeeping 33 min.

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 been postponed from January 1, 1991, to an

undetermined date.

Learning about the law or the form 5 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 more

Cat. No. 12909U Form 4563 (1991)
Form 4563 (1991) 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).

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 were being written defining the bona fide

residence test under section 931. 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 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).

● 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: You can take a deduction for each exemption you are

entitled to claim. This deduction is not considered allocable

to the excluded income.

What Income Can Be Excluded Self-Employed Individuals

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

can exclude them from your gross income. Use Schedule SE

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

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 Where To File

U.S. Possessions, for information on how to determine the

source of income.

Mail your return to the Internal Revenue Service Center,

Philadelphia, PA 19255, U.S.A.

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.

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

Even if you qualify for the exclusion, you must still report on

Form 1040 your worldwide income. This includes all income

you received during 1991 that does not qualify for the

exclusion. The source of that income does not matter.