Exclusion of Income for Bona Fide Residents                                        OMB No. 1545-0074
Form 4563                                                  of American Samoa 
(Rev. September 2018) 
                                                                                                                           Attachment   
Department of the Treasury                                     ▶ Attach to Form 1040.                                      Sequence No. 68 
Internal Revenue Service                      ▶ Go to www.irs.gov/Form4563 for the latest information.       
Name(s) shown on Form 1040                                                                                          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                of the Treasury, Internal RevenueService      Center, Austin, TX 
otherwise noted.                                                          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 Form 1040. Report all your taxable income, 
Who qualifies. You generally qualify for the exclusion if you             including income from U.S., foreign, and possession sources. 
were a bona fide resident of American Samoa for the entire tax            Send your return to the address shown in the Form 1040 
year and your income was:                                                 instructions. 
• 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 Form 1040. 
Employees of the United States. You may not exclude                       Part II—Figure Your Exclusion 
amounts paid to you for services you performed as anemployee              On lines 7 through 14 include only income that is from sources 
of the U.S. Government or any of its agencies. This applies to            within American Samoa or effectively connected with the 
both civilian and military employees, but does not include                conduct of a trade or business in American Samoa. For details 
employees of the American Samoa government.                               on how to determine the source of income, see Source of 
Where to file. If you are not enclosing a check or moneyorder,            income next. 
file your Form 1040 (including Form 4563)with       the Department 

For Paperwork Reduction Act Notice, see instructions.                         Cat. No. 12909U                              Form 4563 (Rev. 9-2018) 

Form 4563 (Rev. 9-2018)                                                                                                         Page 2 
Source of income. The rules for determining the source of            Income you must report on Form 1040. You must report on 
income are explained in sections 861 through 865 and section         Form 1040 your worldwide income for the tax year that does not 
937, Regulations section 1.937-2, and chapter 2 of Pub. 570.         qualify for the exclusion. The source of that income does not 
Some general rules are:                                              matter. 
• The source of wages, salaries, or tips is generally where the      Deductions and credits you cannot take on Form 1040. If you 
services are performed. If you worked both in and outside            claim the exclusion, you cannot take any deduction or credit on 
American Samoa, include on line 7 only wages, salaries, or tips      Form 1040 that is definitely related to the excluded income. 
earned while you were in American Samoa.                             Deductions and credits that are not definitely related to a  
  De minimis exception. This is an exception to the general          particular type of income must be allocated between your  
rule for determining the source of income earned in American         excluded income and your other income to find the amount you 
Samoa. Generally, income from American Samoa does not                can take on Form 1040. Examples of deductions that are not 
include compensation for services performed in American              definitely related to a particular type of income are: 
Samoa if during 2018 you:                                            • The standard deduction; and 
• Were a U.S. citizen or resident;                                   • Certain itemized deductions such as medical and dental  
• Were not a bona fide resident of American Samoa;                   expenses, gifts to charity, and real estate taxes and mortgage 
• Were not employed by or under contract with an individual,         interest on your personal residence. 
partnership, or corporation that is engaged in a trade or            For more details, including how to figure the amount allocable 
business in American Samoa;                                          to the excluded income, see chapter 4 of Pub. 570. 
• Temporarily performed services in American Samoa for 90                       If you were a bona fide resident of American Samoa 
days or less; and                                                               for the entire tax year, or were considered a bona fide 
                                                                     ¶
• Earned $3,000 or less from such services.                             !       resident of American Samoa for the entire tax year 
                                                                     CAUTION
  Military spouses. If you are the civilian spouse of a member                  under the special rules for the year of a move (see 
of the U.S. Armed Forces, work in American Samoa, and retain         Pub. 570, chapter 1), but not a U.S. citizen or resident, certain 
a residence or domicile in one of the 50 states or the District of   credits and deductions may not be available to you. See 
Columbia under the Military Spouses Residency Relief Act             Nonresident alien under Bona Fide Resident of American Samoa 
(MSRRA), your wages, salaries, tips, and self-employment             in Pub. 570, chapter 3, for specific information. 
income will not be considered income from American Samoa.            Self-employed individuals. If you were self-employed and  
Under MSRRA, the military spouse must be in American Samoa           your net earnings from self-employment were $400 or more,  
solely to be with his/her service member spouse who is serving       generally you will have to pay self-employment tax on those  
in compliance with military orders. For details on MSRRA, see        earnings even though you can exclude the earnings from your 
Pub. 570.                                                            gross income. Use Schedule SE (Form 1040) to figureany    
• The source of interest income is generally where the payer is      self-employment tax due. 
located. For example, American Samoan source income                  Penalty for Failure To Furnish Information 
includes interest from a certificate of deposit issued by a bank 
or branch of a U.S. bank in American Samoa.                          If you became or ceased to be a bona fide resident of a U.S. 
                                                                     possession, you may be required to file Form 8898. If you fail to 
• Generally, dividends are sourced where the paying                  provide the required information, you may have to pay a $1,000 
corporation is created or organized.                                 penalty for each failure unless you can show the failure was due 
• Alimony received from a person who is a bona fide resident of      to reasonable cause and not willful neglect. This penalty is in 
American Samoa is sourced in American Samoa.                         addition to any criminal penalty provided by law. For details, see 
• Except as provided in regulations, income from sources within      the Instructions for Form 8898. 
the United States or effectively connected with the conduct of a 
trade or business in the United States is not income from            Paperwork Reduction Act Notice. We ask for the information 
American Samoa.                                                      on this form to carry out the Internal Revenuelaws  of the United 
• The source of gains, profits, or income from the sale or           States. You are required to give us theinformation. We need it 
disposition of real property (and any interest in real property) is  to ensure that you are complying with these laws and to allow 
generally where the real property is located.                        us to figure and collect the right amount of tax. 
  Personal property. The source of income from the sale of           You are not required to provide the information requested on 
nondepreciable personal property is generally the seller’s           a form that is subject to the Paperwork Reduction Act unless 
residence. For example, if you are a bona fide resident of           the form displays a valid OMB control number. Books or 
American Samoa, gain from the sale or disposition of personal        records relating to a form or its instructions must be retained as 
property is generally from sources within American Samoa.            long as their contents may become material in the 
Income from the sale of inventory is generallysourced where          administration of any Internal Revenue law. Generally, tax 
the title to the property passes. See section865 for details.        returns and return information are confidential, as required by 
                                                                     section 6103. 
          Special rules may apply to bona fide residents of U.S.     The average time and expenses required to complete and file 
          territories who have gain from dispositions of certain     this form will vary depending on individual circumstances. For 
¶!        investment property within the 10-year period              the estimated averages, see the instructions for your income tax 
CAUTION   beginning when they became a bona fide resident.           return. 
For details, see Special Rules for Gains From Dispositions of 
Certain Property, in chapter 2 of Pub. 570, Regulations section      If you have suggestions for making this form simpler, we 
1.937-2(f)(1), and Examples 1 and 2 of section 1.937-2(k).           would be happy to hear from you. See the instructions for your 
                                                                     income tax return. 
Filing Form 1040 
To exclude your qualifying income from American Samoa,  
complete Form 4563 and attach it to your Form 1040.