skip navigation

Search Help
Navigation Help

Tax Map Index
ABCDEFGHI
JKLMNOPQR
STUVWXYZ#

International
Tax Topic Index

Affordable Care Act
Tax Topic Index

FAQs
Forms
Publications
Tax Topics

Comments
About Tax Map

IRS.gov Website
Publication 570
taxmap/pubs/p570-019.htm#en_us_publink1000221432

Chapter 5
Illustrated Examples(p24)

Use the following examples to help you complete the correct attachment to your Form 1040. The completed form for each example is shown on the pages that follow.
taxmap/pubs/p570-019.htm#en_us_publink1000221433

Illustrated Example
of Form 4563(p24)

rule
John Black is a U.S. citizen, single, and under 65. He was a bona fide resident of American Samoa during all of 2013. John must file Form 1040 because his gross income from sources outside the possessions ($10,000 of dividends from U.S. corporations) is more than his adjusted filing requirement for single filers under 65. (See Filing Requirement if Possession Income Is Excluded in chapter 4.) Because he must file Form 1040 (not illustrated), he fills out Form 4563 to determine the amount of income from American Samoa he can exclude. See Bona Fide Resident of American Samoa in chapter 3.
taxmap/pubs/p570-019.htm#en_us_publink1000221434

Completing Form 4563.(p24)

rule
John enters his name and social security number at the top of the form.
taxmap/pubs/p570-019.htm#en_us_publink1000221435
Line 1.(p24)
On Form 4563 (see later), John enters the date his bona fide residence began in American Samoa, June 2, 2012. Because he is still a bona fide resident, he enters "not ended" in the second blank space.
taxmap/pubs/p570-019.htm#en_us_publink1000221436
Line 2.(p24)
He checks the box labeled "Rented house or apartment" to describe his type of living quarters in American Samoa.
taxmap/pubs/p570-019.htm#en_us_publink1000221437
Lines 3a and 3b.(p24)
He checks "No" on line 3a because no family members lived with him. He leaves line 3b blank.
taxmap/pubs/p570-019.htm#en_us_publink1000221438
Lines 4a and 4b.(p24)
He checks "No" on line 4a because he did not maintain a home outside American Samoa. He leaves line 4b blank.
taxmap/pubs/p570-019.htm#en_us_publink1000221439
Line 5.(p24)
He enters the name and address of his employer, Samoa Products Co. It is a private American Samoa corporation.
taxmap/pubs/p570-019.htm#en_us_publink1000221440
Line 6.(p24)
He enters the dates of his 2-week vacation to New Zealand from November 11 to November 25. That was his only trip outside American Samoa during the year.
taxmap/pubs/p570-019.htm#en_us_publink1000221441
Line 7.(p24)
He enters the $24,000 in wages he received from Samoa Products Co.
taxmap/pubs/p570-019.htm#en_us_publink1000221442
Line 9.(p24)
He received $220 in dividends from an American Samoa corporation, which he enters here. He also received $10,000 of dividends from a U.S. corporation, but he will enter that amount only on his Form 1040 because the U.S. dividends do not qualify for the possession exclusion.
taxmap/pubs/p570-019.htm#en_us_publink1000221443
Line 15.(p24)
John totals the amounts on lines 7 and 9 to get the amount he can exclude from his gross income in 2013. He will not enter his excluded income on Form 1040. However, he will attach his completed Form 4563 to his Form 1040.