4563 Exclusion of Income for Bona Fide Residents of American

Form

4563

Exclusion of Income for Bona Fide Residents
of American Samoa

(Rev. December 2008)

©

Department of the Treasury
Internal Revenue Service

Attach to Form 1040.

©

Attachment
Sequence No.

See instructions below and on back.

68

Your social security number

Name(s) shown on Form 1040

Part I

OMB No. 1545-0074

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

©

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.
7
8
9
10
11
12

7
8
9
10
11
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

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

13
©

14

Section references are to the Internal Revenue Code unless
otherwise noted.

Instructions
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.
Purpose of form. Use Form 4563 to figure the amount of
income from American Samoa you may exclude from your
gross income.

For Paperwork Reduction Act Notice, see back of form.

15

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:
● From sources within American Samoa, or
● Effectively connected with the conduct of a trade or
business in American Samoa.
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.
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.
Cat. No. 12909U

Form

4563

(Rev. 12-2008)

Form 4563 (Rev. 12-2008)

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.

Part II—Figure Your Exclusion
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.
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.
● 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.
● 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.
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.
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
CAUTION 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).

Filing Form 1040
To exclude your qualifying income from American Samoa,
complete Form 4563 and attach it to your Form 1040.
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.

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2

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.
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
CAUTION 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.
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.

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.
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.
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.
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.