Get the free Dependent Care FSA Reimbursement Claim Form - samuelmerritt

This form is used by employees to claim reimbursement for eligible dependent care expenses incurred under a Flexible Spending Account (FSA) for dependent care, facilitating employment.

How to fill out dependent care fsa reimbursement

How to fill out Dependent Care FSA Reimbursement Claim Form

1. Obtain the Dependent Care FSA Reimbursement Claim Form from your employer's benefits portal or HR department.
2. Fill out your personal information including your name, address, and Employee ID.
3. Provide details about the dependent for whom the care was provided, including their name, age, and relationship to you.
4. List the care provider's information, including their name, address, and taxpayer identification number (TIN) or social security number.
5. Document the dates for which you are claiming reimbursement, specifying the care start and end dates.
6. Itemize the amount of expenses for each date listed, ensuring accurate totals are provided.
7. Sign and date the form, certifying that the information provided is accurate and true.
8. Submit the completed form along with any required receipts or supporting documentation to your employer’s benefits department.

Who needs Dependent Care FSA Reimbursement Claim Form?

1. Employees who incur expenses for child or dependent care in order to work or look for work.
2. Parents or guardians enrolled in a Dependent Care Flexible Spending Account (FSA).
3. Individuals seeking reimbursement for care services provided to qualifying dependents.

People Also Ask about

How to submit a claim for dependent care in FSA?

Dependent Care FSA Use the FSAFEDS app to have the dependent care provider certify the service by providing a signature on your mobile device. Have the dependent care provider certify the service by signing the completed claim form (PDF). Submit a claim (PDF) with an itemized statement from the dependent care provider.

How do I get reimbursed for FSA eligible expenses?

Supporting documentation for your claim should be an itemized statement from the dependent care provider that includes: service date(s), the dependent's name, the type of service, amount billed, and provider's name and address. You may not submit a canceled check as supporting documentation.

What is acceptable documentation for FSA?

For office visits: Your health plan's Explanation of Benefits (EOB) statement or an itemized receipt or bill from the provider that includes the patient's name, a description of the service, the original date of service and your portion of the charge.

How to submit a claim for dependent care in FSA?

Dependent Care FSA Use the FSAFEDS app to have the dependent care provider certify the service by providing a signature on your mobile device. Have the dependent care provider certify the service by signing the completed claim form (PDF). Submit a claim (PDF) with an itemized statement from the dependent care provider.

Can I get reimbursed from my dependent care FSA?

You can only be reimbursed for expenses that occur and are paid during the plan year. So you can't be reimbursed for 2018 expenses with 2019 funds, even if you pay for it in 2018.

How to submit a receipt for FSA reimbursement?

Employers may make contributions to your FSA, but they aren't required to. With an FSA, you submit a claim to the FSA (through your employer) with proof of the medical expense and a statement that it hasn't been covered by your plan. Then, you'll get reimbursed for your costs.

What documentation do I need for dependent care FSA?

Start and end dates of service • Dependent's name and date of birth • Itemization of charges • Provider's name, address, and tax ID or Social Security number • Credit card receipts, canceled checks, and balance forward statements do not meet the requirements for acceptable documentation.

Are there tax documents for dependent care FSA?

You're receiving a tax benefit because under the plan, you're not paying taxes on the money set aside to pay for the dependent care expenses. You must complete and attach Form 2441, Child and Dependent Care Expenses to your tax return.

Does the IRS require receipts for FSA?

Please save your receipts and other supporting documentation related to your HC FSA expenses and claims. The IRS may request itemized receipts to verify the eligibility of your expenses. Credit card receipts, canceled checks, and balance forward statements do not meet the requirements for acceptable documentation.

For pdfFiller’s FAQs

What is Dependent Care FSA Reimbursement Claim Form?

The Dependent Care FSA Reimbursement Claim Form is a document used by employees to request reimbursement for eligible dependent care expenses from their Flexible Spending Account (FSA).

Who is required to file Dependent Care FSA Reimbursement Claim Form?

Employees who have incurred eligible dependent care expenses and want to be reimbursed from their Dependent Care FSA are required to file this form.

How to fill out Dependent Care FSA Reimbursement Claim Form?

To fill out the form, you need to provide your personal information, details of the dependent care expenses, amount being claimed, and any required documentation such as receipts or invoices.

What is the purpose of Dependent Care FSA Reimbursement Claim Form?

The purpose of the form is to facilitate the reimbursement process for employees who have paid for eligible dependent care services, allowing them to recover costs incurred while they work.

What information must be reported on Dependent Care FSA Reimbursement Claim Form?

The form must include the employee's name, employee ID, dependent's name, care provider's information, dates of service, amounts paid, and any supporting documentation of the expenses.