Form 4563 (Revised December 2011) Exclusion of Income for Bona Fide Residents of American Samoa

Summary: This is an example of Form 4563 (Revised December 2011) with items included as described in the text. Additionally, these line items are completed:

Name(s) shown on Form 1040 field contains John Black
Your social security number field contains 111-00-1111
UnderPart I: General Information:
- 1 Date bona fide residence began field contains 6-2-2010
- and ended field contains not ended
- 2 Type of living quarters in American Samoa field contains rented house or apartment
- 3a Did any of your family live with you in American Samoa during any part of the tax year? field contains no
- 4a Did you maintain any home(s) outside American Samoa? field contains no
- 5 Name and address of employer (state if self-employed) field contains Samoa Products, Co., Pago Pago, American Samoa
- 6 Complete columns (a) through (d) below for days absent from American Samoa during the tax year field contains 11-11-2011, 11-25-2011, 14, Vacation to New Zealand
UnderPart II: Figure Your Exclusion. Include only income that qualifies for the exclusion. See instructions:
7 Wages, salaries, tips, etc. field contains 24,000
9 Ordinary dividends field contains 220
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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