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# of Pages Transmitted Section 125 Flexible Benefit Plan DEPENDENT CARE REIMBURSEMENT REQUEST “Please Print Name of Employee: SSN: (required) Address: Address Change: Yes City×State×Zip: Email

How to fill out 125 dependent care claim

Who needs 125 dependent care claim?

1. Employees who have dependents and pay for dependent care expenses may need to fill out a 125 dependent care claim. This includes parents or guardians who have children under the age of 13.
2. Self-employed individuals or business owners who offer dependent care benefits to their employees may also need to provide a 125 dependent care claim form to their workers.
3. Individuals who participate in a flexible spending account (FSA) or a dependent care assistance program (DCAP) may need to fill out a 125 dependent care claim to seek reimbursement for eligible expenses.

How to fill out a 125 dependent care claim?

1. Obtain the necessary form: Contact your employer, benefits administrator, or insurance provider to obtain the specific 125 dependent care claim form. It may also be available on their website or through an online portal.
2. Provide personal information: Start by filling out personal information such as your full name, employee ID or Social Security number, mailing address, and contact details.
3. Dependent information: Enter the names, ages, and relationships of your dependents for whom you are seeking dependent care benefits. Ensure the information is accurate and up-to-date.
4. Provider details: Include the name, address, and contact information of the dependent care service provider. This may be a daycare center, babysitter, or licensed caregiver.
5. Dates of service: Specify the dates during which the dependent care services were provided. This should cover the period for which you are seeking reimbursement or utilizing your dependent care benefits.
6. Expense details: Indicate the total amount of eligible dependent care expenses incurred during the specified timeframe. This may include expenses such as daycare fees, after-school programs, summer camps, or in-home care service costs.
7. Employer contributions: If your employer or business provides any contributions towards dependent care expenses, ensure to accurately report these amounts.
8. Sign and date: Carefully review the filled-out form for any errors or missing information. Sign and date the form to certify its accuracy.
9. Submission: Follow the instructions provided by your employer or benefits administrator for submitting the completed 125 dependent care claim form. This may involve submitting the form physically or through an online portal.
10. Retain copies: Make copies of the filled-out form and any supporting documentation, such as receipts or invoices, for your records. These may be needed for verification or future reference.

Remember, it is essential to understand the specific guidelines and requirements of your employer or benefits program when filling out a 125 dependent care claim.

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What is 125 dependent care claim?

A 125 dependent care claim is a type of flexible spending account that allows employees to set aside pre-tax dollars to pay for eligible dependent care expenses.

Who is required to file 125 dependent care claim?

Employees who have dependents and incur eligible dependent care expenses are required to file a 125 dependent care claim.

How to fill out 125 dependent care claim?

Employees can fill out a 125 dependent care claim by obtaining the necessary forms from their employer, providing information about their eligible dependent care expenses, and submitting the claim for reimbursement.

What is the purpose of 125 dependent care claim?

The purpose of a 125 dependent care claim is to help employees save money on eligible dependent care expenses by allowing them to use pre-tax dollars to pay for these expenses.

What information must be reported on 125 dependent care claim?

Information that must be reported on a 125 dependent care claim includes the employee's eligible dependent care expenses, the dates of service, and any other required documentation.