Form 4563 Exclusion of Income for Bona Fide Residents of American

Form

4563

Exclusion of Income for Bona Fide Residents
of American Samoa

(Rev. December 2011)
Department of the Treasury
Internal Revenue Service

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Attach to Form 1040.

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Attachment
Sequence No. 68

See instructions below and on back.

Your social security number

Name(s) shown on Form 1040

Part I

OMB No. 1545-0074

General Information

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Date bona fide residence began ▶
, and ended ▶
Rented room
Rented house or apartment
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Type of living quarters in
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
b If “Yes,” who and for what period? ▶

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. ▶
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Name and address of employer (state if self-employed)

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Complete columns (a) through (d) below for days absent from American Samoa during the tax year.
(a) Date left

Part II

(b) Date
returned

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(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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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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ▶

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

Instructions
Purpose of form. Use Form 4563 to figure the amount of
income from American Samoa you may exclude from your
gross income.
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. If you are not enclosing a check or money order,
file your Form 1040 (including Form 4563) with the Department

For Paperwork Reduction Act Notice, see Form 1040 instructions.

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of the Treasury, Internal Revenue Service Center, Austin, TX
73301-0215 USA.
If you are including a check or money order, file your return
with the Internal Revenue Service, P.O. Box 1303, Charlotte, NC
28201-1303 USA.
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.
Additional information. Pub. 570, Tax Guide for Individuals
With Income From U.S. Possessions, 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, later.
Cat. No. 12909U

Form 4563 (Rev. 12-2011)

Page 2

Form 4563 (Rev. 12-2011)

Source of income. The rules for determining the source of
income are explained in sections 861 through 865 and section
937, Regulations section 1.937-2, and 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.
Military spouses. If you are the civilian spouse of a member
of the U.S. Armed Forces, work in American Samoa, and retain
a residence or domicile in one of the 50 states or the District of
Columbia under the Military Spouses Residency Relief Act
(MSRRA), your wages, salaries, tips, and self-employment
income will not be considered income from American Samoa.
Under MSRRA, the military spouse must be in American Samoa
solely to be with his/her service member spouse who is serving
in compliance with military orders. MSRRA applies to qualified
individuals for the 2009 calendar year or subsequent years. For
details on MSRRA, see Pub. 570.
• 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.
• 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 any interest in real property) is
generally 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.
De minimis exception. This is an exception to the general
rule for determining the source of income earned in American
Samoa. Generally, income from American Samoa does not
include compensation for services performed in American
Samoa if during 2011 you:
• Were a U.S. citizen or resident,
• Were not a bona fide resident of American Samoa,
• Were not employed by or under contract with an individual,
partnership, or corporation that is engaged in a trade or
business in American Samoa,
• Temporarily performed services in American Samoa for 90
days or less, and
• Earned $3,000 or less from such services.
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
CAUTION
beginning when they became a bona fide resident.
For details, see Special Rules for Gains From Dispositions of
Certain Property, in chapter 2 of Pub. 570, Regulations section
1.937-2(f)(1), and Examples 1 and 2 of section 1.937-2(k).

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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.
Deduction and credits you cannot take on Form 1040. If you
claim the exclusion, you cannot 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
can 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 can 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
CAUTION
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. See
Nonresident alien under Bona Fide Resident of American Samoa
in Pub. 570, chapter 3, for specific information.
Self-employed individuals. If you were self-employed and
your net earnings from self-employment were $400 or more,
generally you will have to pay self-employment tax on those
earnings even though you can exclude the earnings from your
gross income. Use Schedule SE (Form 1040) to figure any
self-employment tax due.

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Penalty for Failure To Furnish Information
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 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. For details, see the Instructions for Form 8898.
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.