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Publication 570

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.

Illustrated Example
of Form 4563(p24)

John Black is a U.S. citizen, single, and under 65. He was a bona fide resident of American Samoa during all of 2012. 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.

Completing Form 4563.(p24)

John enters his name and social security number at the top of the form.
Line 1.(p24)
On Form 4563 (see page 25), John enters the date his bona fide residence began in American Samoa, June 2, 2011. Because he is still a bona fide resident, he enters "not ended" in the second blank space.
Line 2.(p24)
He checks the box labeled "Rented house or apartment" to describe his type of living quarters in American Samoa.
Lines 3a and 3b.(p24)
He checks "No" on line 3a because no family members lived with him. He leaves line 3b blank.
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.
Line 5.(p24)
He enters the name and address of his employer, Samoa Products Co. It is a private American Samoa corporation.
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.
Line 7.(p24)
He enters the $24,000 in wages he received from Samoa Products Co.
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.
Line 15.(p24)
John totals the amounts on lines 7 and 9 to get the amount he can exclude from his gross income in 2012. He will not enter his excluded income on Form 1040. However, he will attach his completed Form 4563 to his Form 1040.