Form 2555 Foreign Earned Income 2004. Summary: This is an example of Form 2555 (2004) as pertains to the text. The line items are completed as follows:
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“Name shown on Form 1040” field contains James M. Adams
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“Your social security number” field contains 111-00-1111
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Under
“Part I: General Information”:
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“1. Your foreign address (including country)” field contains 10 Wadi Abu Hassan, City A, Country X
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“2. Your occupation” field contains Engineer
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“3. Employer's name” field contains Pan American Oil Company
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“4a. Employer's United States address” field contains Not Applicable
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“4b. Employer's foreign address” field contains 65 Sheik Hussein Street, City A, Country X
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“5. Employer is (check any that apply): a. A foreign entity” checkbox checked
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“6a. If, after 1981, you filed Form 2555 to claim either of the exclusions or Form 2555-EZ to claim the foreign earned income
exclusion, enter
the year you filed the form.” field contains 2003
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“6c. Have you ever revoked either of the exclusions? No” checkbox checked
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“7. Of what country are you a citizen/national?” field contains United States
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“8a. Did you maintain a separate foreign residence for your family because of adverse living conditions at your tax home? See
Second foreign
household on page 3 of the instructions. Yes” checkbox checked
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“8b. If Yes, enter city and country of the separate foreign residence. Also, enter the number of days during your tax year
that you maintained
a second household at that address.” field contains Paris, France 366 days
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“9. List your tax home(s) during your tax year and date(s) established.” field contains City A, Country X
6-9-98
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