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.

Purpose of Form

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

you may exclude from your gross income.

(Rev. December 2005)

Part I

Part II

General Information

b

b

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

What’s New

● The rules for determining whether you are a bona fide

resident of American Samoa have changed. See Bona Fide

Residence Test on this page.

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 on this page.

TIP

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.

Bona Fide Residence Test

To qualify under this test, you must be a bona fide resident of

American Samoa for the entire tax year (January 1 through

December 31 if you file a calendar year return).

● Are present in American Samoa for at least 183 days,

In general, for tax years beginning after October 22, 2004,

you are a bona fide resident of American Samoa if, during the

tax year, you:

● Do not have a tax home outside of American Samoa, and

● Do not have a closer connection to the United States or a

foreign country than to American Samoa.

For Paperwork Reduction Act Notice, see back of form. Cat No. 12909U Form 4563 (Rev. 12-2005)

● If, in tax year 2001 or later, you become 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.
Form 4563 (Rev. 12-2005) Page 2

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:

For more details, including how to figure the amount

allocable to the excluded income, see Pub. 570.

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, and

● Income effectively connected with the conduct of a trade

or business in American Samoa.

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

Pub. 570.

Mail your return to the Internal Revenue Service Center,

Philadelphia, PA 19255, 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.

Mail your return to the address shown in the Form 1040

instructions. 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.

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.

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.

For more information about bona fide residence, including

special rules for meeting the 183-day test, see Pub. 570, Tax

Guide for Individuals With Income From U.S. Possessions.

Your tax home is your regular or principal place of business

or employment, regardless of where you maintain your family

residence. If you do not have a regular or principal place of

business because of the nature of your work, your tax home is

the place where you live on a regular basis. If you were a bona fide resident of American

Samoa for the entire tax year, but not a U.S. citizen

or resident, certain credits and deductions may not

CAUTION be available to you.