Get the free Dependent Care Claim Form - Health Sciences Association

FIN-16.06 (a) DEPENDENT CARE Claim Form Use this form for reimbursement of dependent care costs for services provided in your home or community. Please return this form to HSA along with a copy of

How to fill out dependent care claim form

How to Fill Out Dependent Care Claim Form:

1. Gather necessary information: Before starting to fill out the dependent care claim form, make sure you have all the required information handy. This may include the name and address of the dependent care provider, the total amount paid for dependent care expenses during the applicable period, and any additional documentation requested.
2. Provide personal details: Begin by filling out the personal information section of the form accurately. This typically includes your name, address, social security number, and employer information. Ensure that all details are entered correctly to prevent any processing delays.
3. Specify dependent details: If you are claiming dependent care expenses for a child or other qualifying dependents, provide their names, ages, and social security numbers. It's important to accurately provide this information to ensure the claim is processed correctly.
4. Enter dependent care provider information: Complete the section which requires you to provide details about the dependent care provider. This typically includes their name, address, and tax identification number. Ensure that you have all the necessary information about the provider before filling out this section.
5. List dependent care expenses: Itemize the dependent care expenses you incurred during the applicable period. This may include weekly or monthly fees paid, additional fees for extra services, or any other eligible expenses. Be sure to keep proper documentation and receipts to support your claim if needed.
6. Calculate total expenses: Once you have listed all the relevant dependent care expenses, calculate the total amount paid during the specific period. Double-check your calculations to avoid any errors.
7. Sign and date the form: Review the completed form thoroughly and ensure that all the information provided is accurate. Sign and date the form in the designated section to certify that the information provided is true and complete to the best of your knowledge.

Who needs Dependent Care Claim Form?

The dependent care claim form is typically required by individuals who have dependents and incur eligible expenses for their care. This includes parents or guardians who pay for child care services, as well as individuals who care for dependent adults. Employers may request this form to be completed for the purpose of reimbursement or to help employees access dependent care benefits provided by the company. It's important to consult with your employer or benefits provider to determine if you need to fill out a dependent care claim form.

For pdfFiller’s FAQs

What is dependent care claim form?

The dependent care claim form is a document used to request reimbursement for dependent care expenses.

Who is required to file dependent care claim form?

Individuals who have incurred dependent care expenses and are seeking reimbursement are required to file the dependent care claim form.

How to fill out dependent care claim form?

To fill out the dependent care claim form, you will need to provide information about the dependent care expenses you have incurred, including the dates of service, the name of the care provider, and the amount paid.

What is the purpose of dependent care claim form?

The purpose of the dependent care claim form is to request reimbursement for dependent care expenses incurred by the individual.

What information must be reported on dependent care claim form?

The information that must be reported on the dependent care claim form includes the dates of service, the name of the care provider, and the amount paid for dependent care expenses.

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