Get the free Dependent Care FSA Reimbursement Claim Form

This form is used to claim reimbursement for eligible dependent care expenses through a Flexible Spending Account (FSA). It requires details about the employee, expenses incurred, and certification

How to fill out dependent care fsa reimbursement

How to fill out Dependent Care FSA Reimbursement Claim Form

1. Obtain the Dependent Care FSA Reimbursement Claim Form from your employer or FSA provider.
2. Complete your personal information, including your name, address, and FSA account number.
3. List the name(s) of the dependent(s) for whom the care was provided.
4. Specify the care provider's information, including their name, address, and tax identification number (if applicable).
5. Detail the dates of service, the amount paid for each date, and the type of care provided.
6. Attach any required documentation, such as receipts or invoices, showing payment for the dependent care services.
7. Review the completed form for accuracy and completeness.
8. Sign and date the form to certify that the information provided is correct.
9. Submit the form and any supporting documents to the appropriate claims processing address provided by your FSA administrator.

Who needs Dependent Care FSA Reimbursement Claim Form?

1. Employees who are enrolled in a Dependent Care Flexible Spending Account (FSA) and have incurred expenses for child care or adult dependent care during the plan year.

People Also Ask about

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.

How do I get reimbursed for FSA eligible expenses?

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 acceptable documentation for FSA?

For office visits: Your health plan's Explanation of Benefits (EOB) statement or an itemized receipt or bill from the provider that includes the patient's name, a description of the service, the original date of service and your portion of the charge.

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.

Can I get reimbursed from my dependent care FSA?

You can only be reimbursed for expenses that occur and are paid during the plan year. So you can't be reimbursed for 2018 expenses with 2019 funds, even if you pay for it in 2018.

How to submit a receipt for FSA reimbursement?

Employers may make contributions to your FSA, but they aren't required to. With an FSA, you submit a claim to the FSA (through your employer) with proof of the medical expense and a statement that it hasn't been covered by your plan. Then, you'll get reimbursed for your costs.

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.

Are there tax documents for dependent care 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.

Does the IRS require receipts for FSA?

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.

For pdfFiller’s FAQs

What is Dependent Care FSA Reimbursement Claim Form?

The Dependent Care FSA Reimbursement Claim Form is a document that employees use to request reimbursement from their Dependent Care Flexible Spending Account (FSA) for eligible expenses related to the care of dependents.

Who is required to file Dependent Care FSA Reimbursement Claim Form?

Employees who have incurred eligible dependent care expenses and wish to receive reimbursement from their Dependent Care FSA are required to file the form.

How to fill out Dependent Care FSA Reimbursement Claim Form?

To fill out the form, employees should provide their personal information, details of the dependent care provider, the dates of service, the amount being claimed, and attach any necessary receipts or documentation supporting the expenses.

What is the purpose of Dependent Care FSA Reimbursement Claim Form?

The purpose of the form is to facilitate the reimbursement process for employees claiming eligible dependent care expenses, ensuring that the claims comply with IRS guidelines and the specific provisions of the employees' FSA plan.

What information must be reported on Dependent Care FSA Reimbursement Claim Form?

The form must report the employee's name, the dependent's name, the care provider's information, service dates, the type of care provided, and the amount being claimed, along with any supporting receipts or documentation.