Fillable Form 4563 (2019)

What is Form 4563?

Form 4563, Exclusion of Income for Bona Fide Residents of American Samoa, is used by residents of American Samoa to calculate the amount of income from American Samoa a taxpayer may exclude from his or her gross income. American Samoa taxpayers must submit Form 1040, U.S. Individual Income Tax Return, and Form 1040-SR, U.S. Tax Return for Seniors along with this form. If a taxpayer claims his or her gross income exclusion, he or she cannot take any deduction or credit on Form 1040 or 1040-SR that is definitely related to the excluded income.

A resident of American Samoa can normally qualify for the gross income exclusion if he or she was a bona fide resident of American Samoa for the entire tax year and his or her income applies to the following:

• From sources within American Samoa
• Effectively connected with the conduct of a trade or business in American Samoa

If the taxpayer is an employee from the United States, he or she may not exclude any amounts paid to him or her for the services he or she has performed as an employee of the U.S. Government or any of its agencies. This will apply to both civilian and military employees, but does not include any employee of the American Samoa government.

A resident of American Samoa who is filling out this form must only enter his or her income that is from sources within American Samoa or effectively connected with the conduct of a trade or business in American Samoa. The income a taxpayer must enter should be able to qualify for gross income exclusion for the tax year.

The source of wages, salaries, or tips is generally where the services are performed. If a resident of American Samoa worked both in and outside American Samoa, he or she must only include wages, salaries, or tips earned while he or she was in American Samoa; although there is an exception to the general rule for determining the source of income earned in American Samoa.

Normally, income gained in American Samoa does not include compensation for services performed in American Samoa if the following qualifications apply to a certain taxpayer:

• Were a U.S. citizen or resident
• Were not a bona fide resident of American Samoa
• Were not employed by or under contract with an individual, partnership, or corporation that is engaged in a trade or business in American Samoa
• Temporarily performed services in American Samoa for 90 days or less
• Earned $3,000 or less from such services

How to fill out Form 4563?

Residents of American Samoa can download and print a PDF copy of Form 4563 from the Internal Revenue Service (IRS) website that they can manually complete. They can also fill out Form 4563 electronically on PDFRun.

To fill out Form 4563, you must provide the following information:

Name shown on Form 1040 or 1040-SR

Enter your full legal name. The name you will enter here must be the same one you have entered on Form 1040, U.S. Individual Income Tax Return, and on Form 1040-SR, U.S. Tax Return for Seniors.

Your Social Security Number (SSN)

Enter your social security number (SSN).

Part I. General Information

Line 1. Date bona fide residence began and ended

Enter the date when your bona fide residency began and ended.

Line 2. Type of living quarters in American Samoa

Mark the appropriate box which corresponds to the type of living quarters you resided in American Samoa. You may select:

• Rented room
• Rented house or apartment
• Quarters furnished by employer
• Purchased home

Line 3a

Mark YES if any members of your family lived with you in American Samoa during any part of the tax year; otherwise, mark NO.

Line 3b

If you marked YES in the previous line, enter the full legal names of the family members who lived with you and enter the period as well.

Line 4a

Mark YES if you have maintained any homes outside of American Samoa; otherwise, mark NO.

Line 4b

If you marked YES to the previous line, enter the address of your home regardless if it was rented. You must also enter the full legal name of each occupant living in your home and his or her relationship to you.

Line 5. Name and address of employer

Enter the full legal name of your employer along with his or her residential address. If you are self-employed, state it in this line.

Line 6

Complete the columns (a) through (d) below for the days you have been absent from American Samoa during the tax year.

A. Date left

Enter the date when you left American Samoa.

B. Date returned

Enter the date when you have returned to American Samoa.

C. Number of days absent

Enter the number of days you have been absent from American Samoa during the tax year.

D. Reason for absence

Enter all of the valid reasons for your absence during the tax year in American Samoa.

Part II. Figure Your Exclusion

You must only include the income that is from sources within American Samoa or effectively connected with the conduct of a trade or business in American Samoa to qualify for the exclusion from your gross income this tax year.

Line 7. Wages, salaries, tips, etc.

Enter the total amount of your wages, salaries, tips, and other similar types of income.

Line 8. Taxable interest

Enter any taxable interest that may apply.

Line 9. Ordinary dividends

Enter all of your ordinary dividends.

Line 10. Business income

Enter the total amount of your business income.

Line 11. Capital gain

Enter the total amount of your capital gain.

Line 12. Rental real estate, royalties, etc.

Enter the total amount you received from rental real estate, royalties, and other similar types of income.

Line 13. Farm income

Enter the total amount of your farm income.

Line 14. Other income

Enter any other income you may have.

Line 15. Exclusion from gross income

Add the amounts in lines 7 through 14 and enter the total amount you may exclude from your gross income this tax year.