Get the free Dependent Care Claim Form

This form is required for reimbursement from the Dependent Care Spending Account and must be completed with appropriate documentation such as itemized daycare receipts.

How to fill out dependent care claim form

How to fill out Dependent Care Claim Form

1. Obtain the Dependent Care Claim Form from your employer or benefits administrator.
2. Fill out your personal information, including your name, address, and employee identification number.
3. Enter the information for each dependent for whom you are claiming care expenses, including their names and relationship to you.
4. Provide details of the care provider(s), including their name, address, and taxpayer identification number (TIN) or Social Security number.
5. List the dates and amounts of care expenses incurred for each dependent during the claim period.
6. Attach any required documentation, such as receipts or invoices from the care provider.
7. Sign and date the form to certify that the information provided is accurate and complete.
8. Submit the completed form and documentation to the appropriate department by the specified deadline.

Who needs Dependent Care Claim Form?

1. Parents or guardians of children under 13 years old who have incurred expenses for childcare services.
2. Individuals who are caring for a dependent adult who is unable to care for themselves due to physical or mental limitations.

People Also Ask about

How do I report dependent care FSA on W-2?

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 claim for dependent care in FSA?

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 the form for dependent care credit?

Form 2441 is used to claim the Child and Dependent Care Credit, which is available to those who pay someone to care for dependent children under 13, disabled spouses, or other dependents who cannot mentally or physically care for themselves.

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.

How do I claim dependent care expenses on my taxes?

Reporting on your tax return If you qualify for the credit, complete Form 2441, Child and Dependent Care Expenses and attach to Form 1040, U.S Individual Income Tax Return, Form 1040-SR, U.S. Tax Return for Seniors or Form 1040-NR, U.S. Nonresident Alien Income Tax Return.

For pdfFiller’s FAQs

What is Dependent Care Claim Form?

The Dependent Care Claim Form is a document used to request reimbursement for eligible dependent care expenses incurred while the taxpayer or employee is working or seeking employment.

Who is required to file Dependent Care Claim Form?

Typically, individuals who have incurred qualifying child or dependent care expenses while working or looking for work are required to file the Dependent Care Claim Form to receive reimbursement.

How to fill out Dependent Care Claim Form?

To fill out the Dependent Care Claim Form, provide personal information, such as name and address, details of the dependent care provider, the total amount spent on care, and the dates services were provided.

What is the purpose of Dependent Care Claim Form?

The purpose of the Dependent Care Claim Form is to enable individuals to claim reimbursement for child and dependent care expenses that allow them to work or seek employment.

What information must be reported on Dependent Care Claim Form?

Information that must be reported on the Dependent Care Claim Form includes the taxpayer's details, dependent's information, provider's name and address, dates of care, and the total amount paid for care.