Fsa Claim Form - Montgomery County Page 2
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Health Care Reimbursement Expenses Filing Instructions
Who is eligible?
· An employee who is enrolled in the plan, and their legal spouse or tax dependent .
Examples of qualifying expenses
Medical, dental, vision, prescriptions and hearing expenses not covered by your health insurance.
Documentation must show
A. The date the expense was incurred (not the date paid).
B. The name of provider of services.
C. A description of the service and/or expense.
D. The amount of the expense for which you are responsible.
Be sure to attach a copy of the itemized receipt(s), or if you have insurance, please send the Explanation of Benefits Statement.
Keep original receipts for your tax records.
Please Note: Cancelled checks, credit card receipts, and balance forward statements are NOT acceptable forms of
documentation.
Dependent Care Reimbursement Expenses Filing Instructions
Who is eligible?
· A “qualifying child or dependent” is someone whose principal place of abode is with you; who is under age 13, or
physically/mentally incapable of caring for him/herself and doesn’t have income in excess of IRS tax code.
Contact your tax or legal counsel if you have questions regarding the definition of “dependent”.
Examples of qualifying expenses
The receipts submitted must be for preschool or daycare expenses, before and after school programs, day camp, or care of
disabled dependents.
Documentation must show
A. The date the services were provided (not the date paid).
B. The name of the provider of services.
C. A description of the service.
D. The amount of the expense for which you are responsible.
E. A provider signature may be obtained using the Providers Signature box on the claim form in lieu of a receipt.
Please note: Cancelled checks, credit card slips, bank statements or statements showing only a balance forward are not
accepted as valid receipts.
Additional Information
Please note: You will be required to provide the name, address and taxpayer ID number (TIN) or, if no TIN, the Social Security
number of the dependent care provider on your federal income tax return. If you plan to claim a federal Dependent Care Credit
on your tax returns, you must first deduct the amount you were reimbursed through your Dependent Care FSA account this year.
· The person providing the dependent care services must not be a parent of the child, a child of yours under the age of 19, or a
dependent for whom you will be entitled to a personal exemption on your federal income tax return.
· The Dependent Care Account is not prefunded. Therefore, you must have sufficient funds in your Dependent Care account to
cover the payment amount you are requesting.
· Expenses must be incurred on or after your effective date for the plan year and before the end of the plan year (or grace
period, if adopted by the employer). In accordance with Internal Revenue Service (IRS) rules, reimbursements will not be
made until the services have been provided.
If you have any additional questions regarding your plan please contact us by phone at (603) 647-4666 or (888) 401-FLEX (3539).
Visit us online at
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