Get the free Dependent Care Spending Account Claim Form

This form is used by employees to request reimbursement for dependent care expenses from their Dependent Care Spending Account. It collects employee and dependent information, reimbursement amounts,

How to fill out dependent care spending account

How to fill out Dependent Care Spending Account Claim Form

1. Obtain the Dependent Care Spending Account Claim Form from your employer or the benefits website.
2. Fill in your personal information at the top of the form, including your name, address, and employee ID.
3. Provide details about the dependent care service provider, including their name, address, and taxpayer identification number.
4. List the dates of service for which you are claiming expenses in the designated section.
5. Record the amount you are claiming for each service provided during those dates.
6. Attach any required receipts or documentation as proof of payment for the services rendered.
7. Sign and date the form to certify that all information provided is true and accurate.
8. Submit the completed form and attachments to your employer's benefits office or the designated claims processor.

Who needs Dependent Care Spending Account Claim Form?

1. Employees who have enrolled in a Dependent Care Spending Account and have incurred eligible dependent care expenses.
2. Parents or guardians seeking reimbursement for care expenses related to children under the age of 13 or dependents who are incapable of self-care.

People Also Ask about

Do I need to report dependent care FSA on taxes?

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.

Does the IRS require receipts for FSA expenses?

Please save your receipts and other supporting documentation related to your HC FSA expenses and claims. The IRS may request itemized receipts to verify the eligibility of your expenses. Credit card receipts, canceled checks, and balance forward statements do not meet the requirements for acceptable documentation.

Do I need a receipt for dependent care FSA?

How Dependent Care FSAs Work. Once you have paid for expenses that qualify for reimbursement from the FSA, you will need to complete a claim form provided by your employer and attach receipts or proof of payment with the form.

Do I need a receipt to claim dependent care 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.

How do I get money from my dependent care account?

You must submit a claim each time you request reimbursement for dependent care expenses, even if you regularly pay your dependent care provider the same amount each week. You will be reimbursed up to the current amount in your DCFSA at the time your claim is processed.

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.

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.

For pdfFiller’s FAQs

What is Dependent Care Spending Account Claim Form?

The Dependent Care Spending Account Claim Form is a document used by employees to request reimbursement for eligible dependent care expenses incurred during the tax year.

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

Employees who have incurred out-of-pocket expenses for dependent care that qualify for reimbursement from their employer-sponsored dependent care spending account are required to file this form.

How to fill out Dependent Care Spending Account Claim Form?

To fill out the form, provide your personal information, details of the dependent care provider, the dates of service, the amount being claimed, and attach any required receipts or documentation.

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

The purpose of the form is to allow employees to claim reimbursement for dependent care costs that help them work or look for work, using pre-tax dollars set aside in a flexible spending account.

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

The information that must be reported includes the participant's name, employee ID, dependent care provider's name, provider's tax ID or Social Security number, total claimed amount, and dates of service.