Form 4563 (Revised December 1998) Exclusion of Income for Bona Fide Residents of American Samoa. Summary: This is an example of Form 4563 (Revised December 1998) with items included as described in the text. Additionally,
these line items
are completed:
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“Name(s) shown on Form 1040” field contains John Black
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“Your social security number” field contains 111-00-1111
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