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Address Postal Code Foreign Code Foreign Address Foreign Address Occupants City Form 2555 Department of the Treasury Internal Revenue Service Foreign Earned Income a Attach to Form 1040. a . OMB No. 1545-0074 20 13 Attachment Sequence No. 34 For Use by U.S. Citizens and Resident Aliens Only Name shown on Form 1040 Your social security number Part I General Information 1 Your foreign address (including country) 2 Your occupation 3 Employer’s name a 4 a Employer’s U.S. address a b Employer’s foreign address a 5 Employer is (check any that apply): F a A foreign entity b A U.S. company c Self d A foreign affiliate of a U.S. company e Other (specify) a 6 a If you previously filed Form 2555 or Form 2555-EZ, enter the last year you filed the form. a b If you did not previously file Form 2555 or 2555-EZ to claim either of the exclusions, check here a and go to line 7. c Have you ever revoked either of the exclusions? .................... Yes No d If you answered “Yes,” enter the type of exclusion and the tax year for which the revocation was effective. a 7 Of what country are you a citizen/national? a 8 a Did you maintain a separate foreign residence for your family because of adverse living conditions at your ............... Yes No b If “Yes,” enter city and country of the separate foreign residence. Also, enter the number of days during your tax year that y ou maintained a second household at that address. a 9 List your tax home(s) during your tax year and date(s) established. a Next, complete either Part II or Part III. If an item does not apply, enter 'NA' If you do not give the information asked for, any exclusion or deduction you claim may be disallowed. Part II Taxpayers Qualifying Under Bona Fide Residence Test (see instructions) 10 Date bona fide residence began a , and ended a 11 Kind of living quarters in foreign country a a Purchased house b Rented house or apartment c Rented room d Quarters furnished by employer 12a Did any of your family live with you abroad during any part of the tax year? ........... Yes No b If “Yes,” who and for what period? a 13 a Have you submitted a statement to the authorities of the foreign country where you claim bona fide residence that you are not a resident of that country? See instructions ............ Yes No b Are you required to pay income tax to the country where you claim bona fide residence? See instructions . Yes No If you answered “Yes” to 13a and “No” to 13b, you do not qualify as a bona fide resident. Do not complete the rest of this part. 14 (a) Date arrived in U.S. (b) Date left U.S. (c) Number of days in U.S. on business (d) Income earned in U.S. on business (attach computation) (a) Date arrived in U.S. (b) Date left U.S. (c) Number of days in U.S. on business (d) Income earned in U.S. on business (attach computation) 15a List any contractual terms or other conditions relating to the length of your employment abroad. a b Enter the type of visa under which you entered the foreign country. a c Did your visa limit the length of your stay or employment in a foreign country? If “Yes,” attach explanation . Yes No d Did you maintain a home in the United States while living abroad? .............. Yes No e If “Yes,” enter address of your home, whether it was rented, the names of the occupants, and their relationship to you. a For Paperwork Reduction Act Notice, see the Form 1040 instructions. Cat. No. 11900P Form 2555 (2013) ** For Rented, only enter the word 'Rented'. If not rented, leave blank. Address Relationship State ZIP Code RENTED Foreign City Foreign Country Foreign City Foreign Country State/Province City State ZIP Code Information about Form 2555 and its separate instructions is at www.irs.gov/form2555 tax home? See Second foreign household in the instructions include the income from column (d) in Part IV, but report it on Form 1040. If you were present in the United States or its possessions during the tax year, complete columns (a)...(d) below. Do not ----------------Page (0) Break---------------- 12-month period.” Do not include the income from column (f) below in Part IV, but report it on Form 1040. Address / City / Province or St / Country / Postal Code Type of Income Partnership's Name Form 2555 Page 3 Spouse Copy Form 2555 (2013) Page 2 Part III Taxpayers Qualifying Under Physical Presence Test (see instructions) 16 The physical presence test is based on the 12-month period from a through a 17 Enter your principal country of employment during your tax year. a 18 foreign countries that did not involve travel on or over international waters, or in or over the United States, for 24 hours or (a) Name of country (including U.S.) (b) Date arrived (c) Date left (d) Full days present in country (e) Number of days in U.S. on business (f) Income earned in U.S. on business (attach computation) Part IV All Taxpayers Note: Enter on lines 19 through 23 all income, including noncash income, you earned and actually or constructively received during constructively received the income. If you are a cash basis taxpayer, report on Form 1040 all income you received in 2013, no matter when you performed the service. 2013 Foreign Earned Income Amount (in U.S. dollars) 19 Total wages, salaries, bonuses, commissions, etc. ............... 19 20 Allowable share of income for personal services performed (see instructions): a In a business (including farming) or profession ................. 20a b In a partnership. List partnership’s name and address and type of income. a 20b 21 Noncash income (market value of property or facilities furnished by employer—attach statement showing how it was determined): a Home (lodging) ........................... 21a b Meals .............................. 21b c Car ............................... 21c d Other property or facilities. List type and amount. a 21d 22 Allowances, reimbursements, or expenses paid on your behalf for services you performed: a Cost of living and overseas differential ......... 22a b Family .................... 22b c Education ................... 22c d Home leave .................. 22d e Quarters ................... 22e f For any other purpose. List type and amount. a 22f g Add lines 22a through 22f ....................... 22g 23 Other foreign earned income. List type and amount. a 23 24 Add lines 19 through 21d, line 22g, and line 23 ................ 24 25 Total amount of meals and lodging included on line 24 that is excludable (see instructions) . . 25 26 foreign earned income ....................... a 26 Form 2555 (2013) Form 2555 Page 3 Taxpayer Copy If you traveled abroad during the 12-month period entered on line 16, complete columns (a)...(f) below. Exclude travel between your 2013 tax year for services you performed in a foreign country. If any of the foreign earned income received this tax year was earned in a prior tax year, or will be earned in a later tax year (such as a bonus), see the instructions. include income from line 14, columnor line 18, column Report amounts in U.S. dollars, using the exchange rates in effect when you actually or (d),(f). Subtract line 25 from line 24. Enter the result here and on line 27 on page 3. This is your 2013 more. If you have no travel to report during the period, enter “Physically present in a foreign country or countries for the entire ----------------Page (1) Break----------------