Exclusion of Income for Bona Fide Residents                                      OMB No. 1545-0074
Form 4563 
(Rev. August 2019)                                     of American Samoa 
                                                       ▶ Attach to Form 1040 or 1040-SR.                              Attachment   
                                                                                                                      Sequence No. 563
Department of the Treasury                 ▶ Go to www.irs.gov/Form4563 for the latest information.       
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                    Rented room                                  Rented house or apartment
       American Samoa                                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 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    (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             Department of the Treasury, Internal Revenue Service, Austin, 
otherwise noted.                                                       TX 73301-0215 USA.
                                                                       If you are including a check or money order, file your return 
Instructions                                                           with the Internal Revenue Service, P.O. Box 1303, Charlotte, NC 
Purpose of form. Use Form 4563 to figure the amount of                 28201-1303 USA. 
income from American Samoa you may exclude from your                   Note: If you do not qualify for the exclusion, follow the  
gross income.                                                          Instructions for Forms 1040 and 1040-SR. Report all your 
Who qualifies. You generally qualify for the exclusion if you          taxable income, including income from U.S., foreign, and 
were a bona fide resident of American Samoa for the entire tax         possession sources. Send your return to the address shown in 
year and your income was:                                              the Instructions for Forms 1040 and 1040-SR. 
• From sources within American Samoa, or                               Additional information. Pub. 570 has more information and an 
• Effectively connected with the conduct of a trade or business        example of how to complete Form 4563. To get Pub. 570, see 
in American Samoa.                                                     How To Get Tax Help in the Instructions for Forms 1040 and 
                                                                       1040-SR. 
Employees of the United States. You may not exclude 
amounts paid to you for services you performed as an employee          Part II—Figure Your Exclusion 
of the U.S. Government or any of its agencies. This applies to         On lines 7 through 14 include only income that is from sources 
both civilian and military employees, but does not include             within American Samoa or effectively connected with the 
employees of the American Samoa government.                            conduct of a trade or business in American Samoa. For details 
Where to file. If you are not enclosing a check or money order,        on how to determine the source of income, see Source of 
file your Form 1040 or 1040-SR (including Form 4563) with the          income next. 

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

Form 4563 (Rev. 8-2019)                                                                                                         Page 2 

Source of income. The rules for determining the source of            Filing Form 1040 or 1040-SR
income are explained in sections 861 through 865 and section         To exclude your qualifying income from American Samoa,  
937, Regulations section 1.937-2, and chapter 2 of Pub. 570.         complete Form 4563 and attach it to your Form 1040 or      
Some general rules are the following.                                1040-SR. 
• The source of wages, salaries, or tips is generally where the      Income you must report on Form 1040 or 1040-SR. You must 
services are performed. If you worked both in and outside            report on Form 1040 or 1040-SR your worldwide income for the 
American Samoa, include on line 7 only wages, salaries, or tips      tax year that does not qualify for the exclusion. The source of 
earned while you were in American Samoa.                             that income does not matter. 
De minimis exception. This is an exception to the general            Deductions and credits you cannot take on Form 1040 or 
rule for determining the source of income earned in American         1040-SR. If you claim the exclusion, you cannot take any 
Samoa. Generally, income from American Samoa does not                deduction or credit on Form 1040 or 1040-SR that is definitely 
include compensation for services performed in American              related to the excluded income.  
Samoa if during 2019 you:
• Were a U.S. citizen or resident;                                   Deductions and credits that are not definitely related to a  
                                                                     particular type of income must be allocated between your  
• Were not a bona fide resident of American Samoa;                   excluded income and your other income to find the amount you 
• Were not employed by or under contract with an individual,         can take on Form 1040 or 1040-SR. Examples of deductions 
partnership, or corporation that is engaged in a trade or            that are not definitely related to a particular type of income are:  
business in American Samoa;                                          • The standard deduction; and 
• Temporarily performed services in American Samoa for 90            • Certain itemized deductions such as medical and dental  
days or less; and                                                    expenses, gifts to charity, and real estate taxes and mortgage 
• Earned $3,000 or less from such services.                          interest on your personal residence. 
Active duty U.S. Armed Forces. If you are a bona fide                For more details, including how to figure the amount allocable 
resident of American Samoa and are stationed outside that            to the excluded income, see chapter 4 of Pub. 570. 
territory, your military compensation will be sourced in American               If you were a bona fide resident of American Samoa 
Samoa under the Servicemembers Civil Relief Act (SCRA). If you                  for the entire tax year, or were considered a bona fide 
are not a bona fide resident of American Samoa but perform           ¶!         resident of American Samoa for the entire tax year 
services in the territory, however, your military compensation       CAUTION    under the special rules for the year of a move (see 
will not be sourced there. For further details, see Pub. 570.        chapter 1 of Pub. 570), but not a U.S. citizen or resident, certain 
Military spouses. If you are the civilian spouse of a member         credits and deductions may not be available to you. See 
of the U.S. Armed Forces, work in American Samoa, and retain         Nonresident alien under Bona Fide Resident of American Samoa 
a residence or domicile in one of the 50 states or the District of   in chapter 3 of Pub. 570 for specific information. 
Columbia under the Military Spouses Residency Relief Act             Self-employed individuals. If you were self-employed and  
(MSRRA), your wages, salaries, tips, and self-employment             your net earnings from self-employment were $400 or more,  
income will not be considered income from American Samoa.            generally you will have to pay self-employment tax on those  
Under MSRRA, the military spouse must be in American Samoa           earnings even though you can exclude the earnings from your 
solely to be with his/her service member spouse who is serving       gross income. Use Schedule SE (Form 1040 or 1040-SR) to 
in compliance with military orders. For details on MSRRA, see        figure any self-employment tax due. 
Pub. 570.
• The source of interest income is generally where the payer is      Penalty for Failure To Furnish Information 
located. For example, American Samoan source income                  If you became or ceased to be a bona fide resident of a U.S. 
includes interest from a certificate of deposit issued by a bank     possession, you may be required to file Form 8898. If you fail to 
or branch of a U.S. bank in American Samoa.                          provide the required information, you may have to pay a $1,000 
• Generally, dividends are sourced where the paying                  penalty for each failure unless you can show the failure was due 
corporation is created or organized.                                 to reasonable cause and not willful neglect. This penalty is in 
• Alimony received from a person who is a bona fide resident of      addition to any criminal penalty provided by law. For details, see 
American Samoa is sourced in American Samoa.                         the Instructions for Form 8898. 
• Except as provided in regulations, income from sources within      Paperwork Reduction Act Notice. We ask for the information 
the United States or effectively connected with the conduct of a     on this form to carry out the Internal Revenue laws of the United 
trade or business in the United States is not income from            States. You are required to give us the information. We need it 
American Samoa.                                                      to ensure that you are complying with these laws and to allow 
• The source of gains, profits, or income from the sale or           us to figure and collect the right amount of tax. 
disposition of real property (and any interest in real property) is  You are not required to provide the information requested on 
generally where the real property is located.                        a form that is subject to the Paperwork Reduction Act unless 
Personal property. The source of income from the sale of             the form displays a valid OMB control number. Books or 
nondepreciable personal property is generally the seller’s           records relating to a form or its instructions must be retained as 
residence. For example, if you are a bona fide resident of           long as their contents may become material in the 
American Samoa, gain from the sale or disposition of personal        administration of any Internal Revenue law. Generally, tax 
property is generally from sources within American Samoa.            returns and return information are confidential, as required by 
Income from the sale of inventory is generally sourced where         section 6103. 
the title to the property passes. See section 865 for details.       The average time and expenses required to complete and file 
          Special rules may apply to bona fide residents of U.S.     this form will vary depending on individual circumstances. For 
          territories who have gain from dispositions of certain     the estimated averages, see the instructions for your income tax 
¶!        investment property within the 10-year period              return. 
CAUTION   beginning when they became a bona fide resident.           If you have suggestions for making this form simpler, we 
For details, see Special Rules for Gains From Dispositions of        would be happy to hear from you. See the instructions for your 
Certain Property in chapter 2 of Pub. 570, Regulations section       income tax return. 
1.937-2(f)(1), and Examples 1 and 2 of section 1.937-2(k).