Dependent Care Fsa Claim Form Page 2
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2How to File a Dependent Care Spending Account Claim
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Step One
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Complete the Employee Information Section of the claim form.
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Step Two
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Complete the section titled Dependent Care Expenses applicable to the type of dependent care provider. Please
remember to include the provider’s tax ID # or SSN. This section must be completed and signed by your Provider
with each submission if you are not attaching an itemized bill. Photocopies of claim forms will not be accepted.
•
Step Three
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Sign and date the section titled Authorization
•
Step Four
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Attach supporting documentation. This must include an itemized bill and proof of payment if your provider
does not complete the provider section on the claim form.
Acceptable supporting documentation includes:
o
Name and address of the day care provider
o
Tax ID Number or Social Security Number of day care provider
o
Dates of services for which you are being charged
o
Provider Signature
o
Amount you are being charged
o
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Step Five
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Retain copies of the entire claim form and supporting documentation for your records. Documents submitted will
not be returned to you.
•
Step Six
- Fax the fully completed Dependent Care Spending Account Claim Form and supporting documentation (if
applicable) to fax number 800 595-4642.
- The forms and supporting documentation may also be mailed to:
Spending Account Service Center
FSA Claims Processing
2300 Renaissance Boulevard
King of Prussia, PA 19406
*Please file your claim promptly, within the plan year in which charges were incurred, if possible. It is not necessary to
accumulate your claims and submit only at year-end. Promptly submitting claims allows additional information to be
requested of you as soon as possible.
Please visit to view your claim and check status. Access information is provided on
your Welcome Letter.
Note:
Any items for which you are reimbursed through your Dependent Care Spending Account cannot be claimed for
credits on your Federal Income Tax Return.
For more information on eligible expense under your Dependent Care Spending Account, please refer to IRS
Publication 503 or the Eligible Expense Guide. Both of which can be found on
For questions regarding Dependent Care Spending Accounts, please contact us at 800-580-6854.
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