Publication 54 - Tax Guide For U.s. Citizens And U.s. Citizens Abroad

673

Department of the Treasury – Internal Revenue Service

Form

OMB No. 1545-1022

Statement For Claiming Benefits Provided

(Rev. March 1997)

by Section 911 of the Internal Revenue Code

(See Instructions on Reverse)

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

Social security number

(please print)

I expect to qualify for the foreign earned income exclusion under either the bona fide residence or physical presence test for calendar

year

or fiscal year

beginning

and ending

Please check applicable box

Bona Fide Residence Test

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) for an uninterrupted period which includes an entire

tax year that began on

,19

(date)

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

, 19

(date within tax year)

I have not stated to the authorities of any foreign country named above that I an 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

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) for

a 12-month period that includes the entire tax year

. Or, if not the entire year, for the part of the tax year beginning on

,19

, and ending on

, 19

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).

Estimated Housing Cost

(1) Rent

(2) Utilities (other than telephone Charges)

(3) Real & Personal Property Insurance

(4) Occupancy tax not deductible under section 164

(5) Nonrefundable fees paid for securing a leasehold

(6) Household Repairs

(7) Add lines 1 through 6

(8) Estimated Base Housing Amount for my qualifying period is

(9) Subtract line 8 from line 7. This is your estimated housing cost amount

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 form 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 form gross income under the

provisions of Code section 911(a).

Your Signature

Date

673

Cat. No. 10183Y

Form

Page 1 (Rev. 03-97)

Chapter 2 Withholding Tax

Page 9

Publication 54 - Tax Guide For U.s. Citizens And U.s. Citizens Abroad - 2001 Page 9

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