Form 4563 (Revised December 2006) Exclusion of Income for Bona Fide Residents of American Samoa. Summary: This is an example of Form 4563 (Revised December 2006) with items included as described in the text. Additionally,
these line items
are completed:
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“Name(s) shown on Form 1040” field contains John Black
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“Your social security number” field contains 111-00-1111
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Under
“Part I: General Information”:
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“1 Date bona fide residence began” field contains 6-2-06
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“and ended” field contains not ended
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“2 Type of living quarters in American Samoa” field contains rented house or apartment
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“3a Did any of your family live with you in American Samoa during any part of the tax year?” field contains no
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“4a Did you maintain home(s) outside American Samoa?” field contains no
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“5 Name and address of employer (state if self-employed)” field contains Samoa Products, Co., Pago Pago, American Samoa
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“6 Complete columns (a) through (d) below for days absent from American Samoa during the tax year” field contains 11-11-07, 11-25-07,
14, Vacation to New Zealand
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Under
“Part II: Figure Your Exclusion. Include only income that qualifies for the exclusion. See instructions”:
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“7 Wages, salaries, tips, etc” field contains 24,000
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“9 Taxable interest” field contains 200
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“15 Add lines 7 through 14. This is the amount you may exclude from your gross income this tax year” field contains
24,220
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