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This document is a reimbursement request form for employees to claim dependent care expenses under the Flexible Benefits Plan administered by Crosby Benefit Systems, Inc.

How to fill out dependent care reimbursement request

How to fill out Dependent Care Reimbursement Request

1. Obtain the Dependent Care Reimbursement Request form.
2. Fill out your personal information at the top of the form.
3. Provide details about the dependent care provider, including their name and address.
4. Enter the dates of service for which you are requesting reimbursement.
5. List the actual amounts paid for each service and the total amount you are requesting.
6. Attach any required documentation, such as receipts or invoices from the care provider.
7. Sign and date the form to certify the information provided is accurate.
8. Submit the completed form and documentation to the appropriate department.

Who needs Dependent Care Reimbursement Request?

1. Employees who incur costs for dependent care while they work.
2. Parents or guardians of children under the age of 13 needing care.
3. Caregivers providing care for disabled dependents of any age.

People Also Ask about

How to reimburse dependent care?

You must submit a claim each time you request reimbursement for dependent care expenses, even if you regularly pay your dependent care provider the same amount each week. You will be reimbursed up to the current amount in your DCFSA at the time your claim is processed.

How to document dependent care FSA expenses?

When submitting a DCFSA claim, either have your dependent care provider certify the service by signing the claim form or provide an itemized statement from the dependent care provider that includes service dates, dependent's name, type of service, amount billed, and the provider's name and address along with a

How to submit receipt for dependent care 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 to submit receipts for dependent care FSA?

Log into your FSA account or use the unique account url provided by your employer. Click "Submit Receipt or Claim." Request "Pay My Provider" for healthcare or Dependent Care and follow the instructions.

How to use PayFlex dependent care?

Use the PayFlex Card®, your account debit card: When you use the PayFlex debit card (if offered), your expense is automatically paid from your FSA. Pay yourself back: Pay for eligible expenses with cash, check or your personal credit card. Then submit a claim to pay yourself back.

What are dependent care benefits?

A Dependent Care FSA (DCFSA) is a pre-tax benefit account used to pay for eligible dependent care services, such as preschool, summer day camp, before or after school programs, and child or adult daycare. It's a smart, simple way to save money while taking care of your loved ones so that you can continue to work.

Can you submit receipts for FSA?

Remember, to be accepted for a claim, you'll need one of the two accepted forms of paperwork: an itemized receipt, or an Explanation of Benefits (EOB) form (which is typically used for eligible medical services).

How do I report dependent care FSA on my taxes?

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.

For pdfFiller’s FAQs

What is Dependent Care Reimbursement Request?

A Dependent Care Reimbursement Request is a form used by employees to claim reimbursement for eligible dependent care expenses incurred while they work or look for work.

Who is required to file Dependent Care Reimbursement Request?

Employees who incur eligible dependent care expenses for their dependents while they are working or searching for work are required to file this request.

How to fill out Dependent Care Reimbursement Request?

To fill out the Dependent Care Reimbursement Request, employees need to provide details such as their name, employee identification number, the period for which the expenses were incurred, the names of the dependents, and the amount of eligible expenses.

What is the purpose of Dependent Care Reimbursement Request?

The purpose of the Dependent Care Reimbursement Request is to allow employees to receive reimbursement for out-of-pocket costs associated with caring for dependents, thus enabling them to work without the burden of childcare costs.

What information must be reported on Dependent Care Reimbursement Request?

The information that must be reported includes the employee's contact details, period of care, names of dependents, type of services provided, and the total amount spent on eligible dependent care.