Form 673 Statement For Claiming Benefits Provided by Section 911 of the Internal Revenue Code (Revision March 1997). Summary: This is an example of Form 673 (Revision March 1997). The text states:The following statement, when completed and furnished by a citizen of the United States to his or her employer, permits the employer to exclude from income tax withholding all or a part of the wages paid for services performed outside the United States.

“Name (please print)” field

“Social Security Number” field

I expect to qualify for the foreign earned income exclusion under either the bona fide resident or physical presence test for calendar year (text field) or fiscal year (text field) beginning (text field) and ending (text field).

Under “Please check applicable box”:

“Bona Fide Resident Test” checkbox I am a citizen of the United States. I have been a bona fide resident of and my tax home has been located in ( “foreign country or countries” field) for an uninterrupted period which includes an entire tax year that began on ( “date” field), 19 (text field). I expect to remain a bona fide resident and retain my tax home in a foreign country (or countries) until the end of the tax year for which this statement is made. Or if not that period, from the date of this statement until ( “date within tax year” field), 19 (text field). I have not stated to the authorities of any foreign country named above that I am not a resident of that country. Or, if I made such a statement, the authorities of that country thereafter made a determination to the effect that I am a resident of that country. Based on the facts in my case, I have good reason to believe that for this period of foreign residence I will satisfy the tax home and the bona fide foreign residence requirements prescribed by the section 911(d)(1)(A) of the Internal Revenue Code and qualify for the exclusion Code section 911(a) allows. “Physical Presence Test” checkbox I am a citizen of the United States. Except for occasional absences that won't disqualify me for the benefit of section 911(a) of the Internal Revenue Code, I expect to be present in and maintain my tax home in ( “foreign country or countries” field) for a 12-month period that includes the entire tax year (text field). Or, if not the entire year, for the part of the tax year beginning on (text field), 19(text field), and ending on (text field), 19(text field). Based on the facts in my case, I have good reason to believe that for this period of presence in a foreign country or countries, I will satisfy the tax home and the 330 full-day requirements within a 12-month period under section 911(d)(1)(B).

Under “Estimated Housing Cost”:

“(1) Rent” field “(2) Utilities (other than telephone charges)” field “(3) Real & Personal Property Insurance” field “(4) Occupancy tax not deductible under section 164” field “(5) Nonrefundable fees paid for securing a leasehold” field “(6) Household Repairs” field “(7) Add lines 1 through 6” field “(8) Estimated Base Housing Amount for my qualifying period is” field “(9) Subtract line 8 from line 7. This is your estimated housing cost amount” field

I understand that this total, plus the total reported on any other statements outstanding with other employers, should not be more than my expected housing cost amount exclusion.If I become disqualified for the exclusions, I will immediately notify my employer and advise what part, if any, of the period I am qualified for.I understand that any exemption from income tax withholding permitted by reason of furnishing this statement is not a determination by the Internal Revenue that any amount paid to me for any services performed during the tax year is excludable from gross income under the provisions of Code section 911(a).

“Your signature” field

“Date” field