Exclusion of Income for Bona Fide Residents                                   OMB No. 1545-0074
Form 4563 
(Rev. September 2024)                                  of American Samoa 
                                                       Attach to Form 1040 or 1040-SR.                             Attachment   
Department of the Treasury                  Go to www.irs.gov/Form4563 for the latest information.                 Sequence No. 563
Internal Revenue Service 
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
     b If “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 their 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    (c)  Number of                             (d)  Reason for absence 
                         returned      days absent 

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            If you are including a check or money order, file your tax 
otherwise noted.                                                      return with the Internal Revenue Service, P.O. Box 1303, 
                                                                      Charlotte, NC 28201-1303 USA. 
Instructions                                                          Note: If you do not qualify for the exclusion, follow the 
Purpose of form. Use Form 4563 to figure the amount of                instructions for your tax return. Report all your taxable income, 
income from American Samoa you may exclude from your                  including income from U.S., foreign, and territory sources. Send 
gross income on your Form 1040 or 1040-SR (your tax return).          your tax return to the address shown in the instructions for your 
Who qualifies. You generally qualify for the exclusion if you         tax return.
were a bona fide resident of American Samoa for the entire tax        Additional information. Pub. 570 has more information on the 
year and your income was:                                             general and special rules for completing Form 4563. To get Pub. 
• From sources within American Samoa, or                              570, go to www.irs.gov/Pub570.
• Effectively connected with the conduct of a trade or business       Part II—Figure Your Exclusion 
in American Samoa.                                                    On lines 7 through 14 include only income that is from sources 
Employees of the United States. You may not exclude                   within American Samoa or effectively connected with the 
amounts paid to you for services you performed as an employee         conduct of a trade or business in American Samoa. For details 
of the U.S. Government or any of its agencies. This applies to        on how to determine the source of income, see Source of 
both civilian and military employees, but does not include            income next. 
employees of the American Samoa government.                           Source of income. The rules for determining the source of  
Where to file. If you are not enclosing a check or money order,       income are explained in sections 861 through 865 and section 
file your tax return (including Form 4563) with the Department of     937, Regulations section 1.937-2, and chapter 2 of Pub. 570. 
the Treasury, Internal Revenue Service, Austin, TX 73301-0215         Some general rules are the following.
USA.
For Paperwork Reduction Act Notice, see instructions.                      Cat. No. 12909U                       Form 4563 (Rev. 9-2024)

Form 4563 (Rev. 9-2024)                                                                                                          Page 2 

• The source of wages, salaries, or tips is generally where the      Filing Form 1040 or 1040-SR
services are performed. If you worked both in and outside            To exclude your qualifying income from American Samoa,  
American Samoa, include on line 7 only wages, salaries, or tips      complete Form 4563 and attach it to your tax return. 
earned while you were in American Samoa. 
  De minimis exception. This is an exception to the general          Income you must report on Form 1040 or 1040-SR. You must 
rule for determining the source of income earned in American         report on your tax return your worldwide income for the tax year 
Samoa. Generally, income from American Samoa does not                that does not qualify for the exclusion. The source of that 
include compensation for services performed in American              income does not matter. 
Samoa if during the tax year you:                                    Deductions and credits you cannot take on Form 1040 or 
• Were a U.S. citizen or resident;                                   1040-SR. If you claim the exclusion, you cannot take any 
                                                                     deduction or credit on your tax return that is definitely related to 
• Were not a bona fide resident of American Samoa;                   the excluded income.  
• Were not employed by or under contract with an individual,         Deductions and credits that are not definitely related to a  
partnership, or corporation that is engaged in a trade or            particular type of income must be allocated between your  
business in American Samoa;                                          excluded income and your other income to find the amount you 
• Temporarily performed services in American Samoa for 90            can take on your tax return. Examples of deductions that are not 
days or less; and                                                    definitely related to a particular type of income are:  
• Earned $3,000 or less from such services.                          • The standard deduction; and 
  Active duty U.S. Armed Forces. If you are a bona fide              • Certain itemized deductions such as medical and dental  
resident of American Samoa and are stationed outside that            expenses, gifts to charity, and real estate taxes and mortgage 
territory, your military compensation will be sourced in American    interest on your personal residence. 
Samoa under the Servicemembers Civil Relief Act (SCRA). If you       For more details, including how to figure the amount allocable 
are not a bona fide resident of American Samoa but perform           to the excluded income, see chapter 4 of Pub. 570. 
services in the territory, however, your military compensation 
will not be sourced there. For further details, see Pub. 570.                   If you were a bona fide resident of American Samoa 
                                                                                for the entire tax year, or were considered a bona fide 
  Military spouses. If you are the civilian spouse of a member       ¶!         resident of American Samoa for the entire tax year 
of the U.S. Armed Forces, work in American Samoa, and retain         CAUTION    under the special rules for the year of a move (see 
a residence or domicile in one of the 50 states or the District of   chapter 1 of Pub. 570), but not a U.S. citizen or resident, certain 
Columbia under the Military Spouses Residency Relief Act             credits and deductions may not be available to you. See 
(MSRRA), your wages, salaries, tips, and self-employment             Nonresident alien under Bona Fide Resident of American Samoa 
income will not be considered income from American Samoa.            in chapter 3 of Pub. 570 for specific information. 
Under MSRRA, the military spouse must be in American Samoa 
solely to be with their service member spouse who is serving in      Self-employed individuals. If you were self-employed and  
compliance with military orders. For details on MSRRA, see           your net earnings from self-employment were $400 or more,  
Pub. 570.                                                            you will generally have to pay self-employment tax on those  
                                                                     earnings even though you can exclude the earnings from your 
• The source of interest income is generally where the payer is      gross income. Use Schedule SE (Form 1040) to figure any self-
located. For example, American Samoan source income                  employment tax due. 
includes interest from a certificate of deposit issued by a bank 
or branch of a U.S. bank in American Samoa.                          Penalty for Failure To Furnish Information 
• Generally, dividends are sourced where the paying                  If you became or ceased to be a bona fide resident of a U.S. 
corporation is created or organized.                                 territory, you may be required to file Form 8898. If you fail to 
• Alimony received from a person who is a bona fide resident of      provide the required information, you may have to pay a $1,000 
American Samoa is sourced in American Samoa.                         penalty for each failure unless you can show the failure was due 
• Except as provided in regulations, income from sources within      to reasonable cause and not willful neglect. This penalty is in 
the United States or effectively connected with the conduct of a     addition to any criminal penalty provided by law. For details, see 
trade or business in the United States is not income from            the Instructions for Form 8898. 
American Samoa. 
• The source of gains, profits, or income from the sale or           Paperwork Reduction Act Notice. We ask for the information 
disposition of real property (and any interest in real property) is  on this form to carry out the Internal Revenue laws of the United 
generally where the real property is located.                        States. You are required to give us the information. We need it 
                                                                     to ensure that you are complying with these laws and to allow 
  Personal property. The source of income from the sale of           us to figure and collect the right amount of tax. 
nondepreciable personal property is generally the seller’s  
residence. For example, if you are a bona fide resident of           You are not required to provide the information requested on 
American Samoa, gain from the sale or disposition of personal        a form that is subject to the Paperwork Reduction Act unless 
property is generally from sources within American Samoa.            the form displays a valid OMB control number. Books or 
Income from the sale of inventory is generally sourced where         records relating to a form or its instructions must be retained as 
the title to the property passes. See section 865 for details.       long as their contents may become material in the 
                                                                     administration of any Internal Revenue law. Generally, tax 
          Special rules may apply to bona fide residents of U.S.     returns and return information are confidential, as required by 
          territories who have gain from dispositions of certain     section 6103. 
¶!        investment property within the 10-year period              The average time and expenses required to complete and file 
CAUTION   beginning when they became a bona fide resident.           this form will vary depending on individual circumstances. For 
For details, see Special Rules for Gains From Dispositions of        the estimated averages, see the instructions for your income tax 
Certain Property in chapter 2 of Pub. 570, Regulations section       return. 
1.937-2(f)(1), and Examples 1 and 2 of section 1.937-2(k). 
                                                                     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.