8844 Empowerment Zone and Renewal Community Employment Credit

Caution: DRAFT FORM
This is an advance proof copy of an IRS tax form.
It is subject to change and OMB approval before it
is officially released. You can check the scheduled
release date on our web site (www.irs.gov).
If you have any comments on this draft form, you can
submit them to us on our web site. Include the word
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Form

I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 4563, PAGE 1 OF 2
MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

4563

Date

©

Department of the Treasury
Internal Revenue Service

Revised proofs
requested

OMB No. 1545-0074

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Attach to Form 1040.

©

Signature

O.K. to print

Exclusion of Income for Bona Fide Residents
of American Samoa

(Rev. December 2006)

Attachment
Sequence No.

See instructions below and on back.

General Information

Date bona fide residence began ©
, and ended ©
Rented room
Rented house or apartment
Type of living quarters in
Quarters furnished by employer
Purchased home
American Samoa
3a Did any of your family live with you in American Samoa during any part of the tax year?
Yes
b If “Yes,” who and for what period? ©
1
2

68

Your social security number

Name(s) shown on Form 1040

Part I

Action

©

No

4a 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

Part II

(b) Date
returned

(c) Number of
days absent

(d) Reason for absence

Figure Your Exclusion. Include only income that qualifies for the exclusion. See instructions.
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8
9
10
11
12

7
8
9
10
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12
13
14

Wages, salaries, tips, etc.
Taxable interest
Ordinary dividends
Business income
Capital gain
Rental real estate, royalties, etc.
Farm income
Other income. List type and amount

15

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

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©

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For Paperwork Reduction Act Notice, see back of form.

Cat. No. 12909U

15

Form

4563

(Rev. 12-2006)