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|Part I Qualification Information for Foreign Earned Income Exclusion|
|I expect to qualify for the foreign earned income exclusion under either the bona fide residence or physical presence test for or other tax and|
|Please check applicable box:|
|I am a citizen of the United States. I have been a bona fide resident of and my tax home has been (foreign country or countries) for an uninterrupted period which includes an entire tax year that , .|
|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 , .|
|I have not submitted a statement 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 resident requirements prescribed by section 911(d)(1)(A) of the Internal Revenue Code and qualify for the exclusion Code section 911(a) allows.|
|I am a citizen of the United States. Except for occasional absences that will not 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 (foreign country or countries) for a 12-month period that includes the entire tax . Or, if not the entire year, for the part of the tax year beginning , , and ,|
|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).|
|Part II Estimated Housing Cost Amount for Foreign Housing Exclusion (see instructions)|
|Part III Certification|
|Under penalties of perjury, I declare that I have examined the information on this form and to the best of my knowledge and belief it is true, correct, and complete. I further certify under penalties of perjury that:|
• The estimated housing cost amount entered in Part II, plus the amount reported on any other statements outstanding with other employers, is not more than my total estimated housing cost amount.
• If I become disqualified for the exclusions, I will immediately notify my employer and advise what part, if any, of the period for which I am qualified.
I understand that any exemption from income tax withholding permitted by reason of furnishing this statement is not a determination by the Internal Revenue Service 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).
Tip: use the US Tax Calculator to edit your refundable and non-refundable tax credits including Form 673: Collection Information Statement for Businesses. Complete, Calculate, print and or save your tax calculation for later use.