Get the free Dependent Care Flexible Spending Account Claim Form

This form allows employees to request reimbursement for dependent care expenses under their Flexible Spending Account, ensuring compliance with relevant IRS guidelines.

How to fill out dependent care flexible spending

How to fill out Dependent Care Flexible Spending Account Claim Form

1. Obtain the Dependent Care Flexible Spending Account Claim Form from your employer or benefits provider.
2. Fill out your personal information, including your name, address, and employee ID number.
3. Provide information about your dependent(s), including their names, ages, and relationship to you.
4. List the care providers used for your dependents along with their names, addresses, and tax identification numbers.
5. Detail the dates of service for each care provided, including start and end dates.
6. Calculate the total amount you are claiming for reimbursement and ensure it does not exceed your annual contribution limit.
7. Sign and date the form to certify that the information provided is accurate and complete.
8. Attach any required documentation, such as receipts or provider statements, that support your claim.
9. Submit the completed form and documentation to your employer or benefits provider as per their instructions.

Who needs Dependent Care Flexible Spending Account Claim Form?

1. Employees who have enrolled in a Dependent Care Flexible Spending Account plan and have incurred eligible dependent care expenses.

People Also Ask about

Do I need a receipt to claim dependent care in FSA?

With a Dependent Care FSA, you use pre-tax dollars to pay qualified out-of-pocket dependent care expenses. The money you contribute to a Dependent Care FSA is not subject to payroll taxes, so you end up paying less in taxes and taking home more of your paycheck.

How to submit dependent care FSA claim?

Keep Your Receipts The IRS may request itemized receipts to verify the eligibility of your expenses.

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.

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.

Is there a tax form for dependent care in 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.

Do I need a receipt to claim dependent care in FSA?

Keep Your Receipts The IRS may request itemized receipts to verify the eligibility of your expenses.

For pdfFiller’s FAQs

What is Dependent Care Flexible Spending Account Claim Form?

The Dependent Care Flexible Spending Account Claim Form is a document used by employees to request reimbursement for eligible dependent care expenses paid for their dependents while they work or look for work.

Who is required to file Dependent Care Flexible Spending Account Claim Form?

Employees who participate in a Dependent Care Flexible Spending Account (FSA) and have incurred eligible dependent care expenses must file the claim form to obtain reimbursement.

How to fill out Dependent Care Flexible Spending Account Claim Form?

To fill out the form, employees should provide their personal information, details of the care provider, specific dates of service, the amount incurred, and attach any required documentation such as receipts or invoices.

What is the purpose of Dependent Care Flexible Spending Account Claim Form?

The purpose of the form is to facilitate the process of claiming reimbursement from the dependent care FSA for qualifying expenses incurred for the care of dependents while the employee works.

What information must be reported on Dependent Care Flexible Spending Account Claim Form?

The form must report the employee's name, employee ID, the name and address of the care provider, dates services were provided, description of services, and the total amount to be reimbursed, along with any necessary receipts.