Publication 54 - Tax Guide For U.s. Citizens And U.s. Citizens Abroad - 2001 Page 27
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44OMB No. 1545-1326
2555-EZ
2
Form 2555-EZ (2001)
Page
Foreign Earned Income Exclusion
2001
Form
Days Present in the United States—
Part III
Complete this part if you were in the
Department of the Treasury
Attachment
United States or its possessions during 2001.
See separate instructions.
Attach to Form 1040.
34A
Internal Revenue Service
(99)
Sequence No.
Name shown on Form 1040
Your social security number
(c) Number of days
(d) Income earned in U.S.
12
(a) Date arrived in U.S.
(b) Date left U.S.
in U.S. on business
on business (attach computation)
Judith E. Adams
222
00
2222
● Are a U.S. citizen or a resident alien.
● Do not have self-employment income.
● Earned wages/salaries in a foreign country.
You May Use
● Do not have business/moving expenses.
● Had total foreign earned income of
This Form
And You:
$78,000 or less.
● Do not claim the foreign housing
If You:
● Are filing a calendar year return that
exclusion or deduction.
covers a 12-month period.
Tests To See If You Can Take the Foreign Earned Income Exclusion
Part I
1
Bona Fide Residence Test
a
Were you a bona fide resident of a foreign country or countries for a period that includes an entire tax year
(see page 2 of the instructions)?
Yes
No
● If you answered “Yes,” you meet this test. Fill in line 1b and then go to line 3.
● If you answered “No,” you do not meet this test. Go to line 2 to see if you meet the Physical Presence Test.
b
Enter the date your bona fide residence began
, and ended (see instructions)
.
2
Physical Presence Test
Figure Your Foreign Earned Income Exclusion
a
Were you physically present in a foreign country or countries for at least 330 full days during—
Part IV
2001 or
Yes
No
any other period of 12 months in a row starting or ending in 2001?
● If you answered “Yes,” you meet this test. Fill in line 2b and then go to line 3.
13
$78,000
00
13
Maximum foreign earned income exclusion
● If you answered “No,” you do not meet this test. You cannot take the exclusion unless you meet the
Bona Fide Residence Test above.
1-1-01
12-31-01
365
14
days
b
The physical presence test is based on the 12-month period from
through
14
Enter the number of days in your qualifying period that fall within 2001
.
15
Did you enter 365 on line 14?
3
Tax Home Test. Was your tax home in a foreign country or countries throughout your period of bona fide
residence or physical presence, whichever applies?
Yes
No
Yes.
Enter “1.000.”
.
● If you answered “Yes,” you can take the exclusion. Complete Part II below and then go to page 2.
1
000
15
No.
Divide line 14 by 365 and enter the result as
● If you answered “No,” you cannot take the exclusion. Do not file this form.
a decimal (rounded to at least three places).
General Information
Part II
78,000
16
16
Multiply line 13 by line 15
4
Your foreign address (including country)
5
Your occupation
17
Enter, in U.S. dollars, the total foreign earned income you earned and received in 2001 (see
44,000
17
instructions). Be sure to include this amount on Form 1040, line 7
21 Rue Reynaud
Paris, France
Secretary
18
Foreign earned income exclusion. Enter the smaller of line 16 or line 17 here and in
6
Employer’s name
7
Employer’s U.S. address (including ZIP code)
8
Employer’s foreign address
parentheses on Form 1040, line 21. Next to the amount enter “2555-EZ.” On Form 1040, subtract
this amount from your income to arrive at total income on Form 1040, line 22
44,000
18
2645 Pewter Place
40 Rue Royale
2555-EZ
Form
A B Insurance Co., Inc.
Anytown, Anystate, U.S.A.
Paris, France
(2001)
9
Employer is (check any that apply):
a
A U.S. business
b
A foreign business
c
Other (specify)
2000
10a
If you filed Form 2555 or 2555-EZ after 1981, enter the last year you filed the form.
b
If you did not file Form 2555 or 2555-EZ after 1981, check here
and go to line 11a now.
c
Have you ever revoked the foreign earned income exclusion?
Yes
No
d
If you answered “Yes,” enter the tax year for which the revocation was effective.
France
6-1-95
11a List your tax home(s) during 2001 and date(s) established.
b Of what country are you a citizen/national?
United States
2555-EZ
For Paperwork Reduction Act Notice, see page 3 of separate instructions.
Cat. No. 13272W
Form
(2001)
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