Form 4563 (Revised August 2019), Exclusion of Income for Bona Fide Residents of American Samoa Form 4563 (Revised August 2019), 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 111-00-1111Under" Part I: General Information": "1 Date bona fide residence began" field contains 6-2-2015 "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 yes "4b. If “Yes,” show address of your home(s), whether it was rented, the name of each occupant, and his or her relationship to you" Field contains: 800 Kennedy Street, Ft. Lauderdale, FL, rental condominium, Bob Wilson. Unrelated "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 11-11-2017, 11-25-2017, 14, Vacation to New ZealandUnder" Part 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
