Get the free Flexible Spending Account Dependent Care Claim Form

A form used for submitting claims for reimbursement of eligible childcare or eldercare expenses under a Flexible Spending Account (FSA).

How to fill out flexible spending account dependent

How to fill out Flexible Spending Account Dependent Care Claim Form

1. Obtain the Flexible Spending Account Dependent Care Claim Form from your employer or the FSA administrator.
2. Fill out your personal information at the top of the form, including your name, address, and account number.
3. Indicate the date(s) of service for which you are claiming reimbursement.
4. Provide details of the dependent care services received, including the provider's name, address, and tax identification number.
5. Enter the amount you are claiming for each date of service in the appropriate section.
6. Attach necessary receipts or documentation proving the expense incurred.
7. Sign and date the form to certify the accuracy of the information provided.
8. Submit the completed claim form and attached documentation to the specified address of your FSA administrator.

Who needs Flexible Spending Account Dependent Care Claim Form?

1. Employees who incur expenses for dependent care services, such as child care or care for disabled dependents, in order to be reimbursed through a Flexible Spending Account.

People Also Ask about

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 you actually save money with an FSA?

A Flexible Spending Account (FSA, also called a “flexible spending arrangement”) is a special account you put money into that you use to pay for certain out-of-pocket health care costs. You don't pay taxes on this money. This means you'll save an amount equal to the taxes you would have paid on the money you set aside.

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 FSA dependent care worth it?

FSA wins easily. Taking dependent care tax credit alone would give you $1200 in tax savings (20% x $6000), and that is all. The dependent care FSA will give you federal tax savings of $1100 (22% x $5000) plus you will save an additional $200 from the remaining $1000 tax credit (20% x $1000).

What is the biggest disadvantage of the FSAs?

Cons of a Flexible Spending Account Use-It-Or-Lose-It Rule: Unused FSA funds are forfeited unless your employer offers a grace period or carryover option. Eligibility Restrictions: FSAs only cover qualifying medical expenses, dental and vision costs, and dependent care 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.

What is the downside to dependent care FSA?

Drawbacks of Dependent Care FSA If money is left over at the end of the year, it doesn't carry over to the next year. If your employer doesn't offer this account, there is no other way to get one. Your FSA can only pay for qualifying expenses, while you're working.

Should I use FSA to pay for daycare?

Yes, as long as the services are necessary for you or your spouse, if married, to work, look for work, or for your spouse to attend school full-time, this is an eligible DCFSA expense.

For pdfFiller’s FAQs

What is Flexible Spending Account Dependent Care Claim Form?

The Flexible Spending Account Dependent Care Claim Form is a document used by employees to request reimbursement for eligible dependent care expenses incurred while they are working or seeking employment.

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

Employees who have enrolled in a Flexible Spending Account for dependent care and have eligible expenses to claim for reimbursement are required to file this form.

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

To fill out the form, provide your personal information, including your name and employee ID; detail the care provider's information; list the dates of service; describe the services provided; and attach any necessary receipts or supporting documents.

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

The purpose of the form is to enable employees to submit claims for reimbursement of qualified dependent care expenses under their Flexible Spending Accounts.

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

The form must report personal details such as the employee’s name, ID, and contact information, details about the dependent(s), the care provider's information, the dates and amounts of care received, and any attached invoices or receipts.