Exclusion of Income for Bona Fide Residents of American Samoa

• Legal Form Number: 4563
• Year: 2019
• Issuer: Treasury Department
• Section: Treasury Department

Form 4563

(Rev. August 2019)

Exclusion of Income for Bona Fide Residents

of American Samoa

Department of the Treasury

Internal Revenue Service

▶ Attach to Form 1040 or 1040-SR.

▶ Go to www.irs.gov/Form4563 for the latest information.

OMB No. 1545-0074

Attachment

Sequence No. 563

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

Part I General Information

1 Date bona fide residence began ▶, and ended ▶

2

Type of living quarters in

American Samoa

▲

Rented room Rented house or apartment

Quarters furnished by employer Purchased home

3 a Did any of your family live with you in American Samoa during any part of the tax year? . . . . . . . Yes No

bIf “Yes,” who and for what period? ▶

4 a 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 (b) Date

returned

(c) Number of

days absent

(d) Reason for absence

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

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

15 Add lines 7 through 14. This is the amount you may exclude from your gross income this tax year ▶15

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 or 1040-SR (including Form 4563) with the

Department of the Treasury, Internal Revenue Service, 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 Forms 1040 and 1040-SR. Report all your

taxable income, including income from U.S., foreign, and

possession sources. Send your return to the address shown in

the Instructions for Forms 1040 and 1040-SR.

Additional information. Pub. 570 has more information and an

example of how to complete Form 4563. To get Pub. 570, see

How To Get Tax Help in the Instructions for Forms 1040 and

1040-SR.

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 next.

For Paperwork Reduction Act Notice, see instructions. Cat. No. 12909U Form 4563 (Rev. 8-2019)