Fsa Worksheet Dependent Care
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1FSA Worksheets
How much you save depends on how much you spend on health and dependent care, and on your tax situation.
To estimate your expenses and see for yourself how your savings can add up, use the savings calculators at:
client .benefitadminsolutions .com/fsaestimator/ for the Health FSA, and at benefitadminsolutions .com/dcapestimator/
calculatedcap .aspx for the Dependent Care FSA.
If you prefer, use the worksheets below to determine how much to contribute to your account(s). Calculate the amount you expect
to pay during the plan year for eligible out-of-pocket medical and/or dependent care expenses. This calculated amount cannot
exceed established IRS and plan limits.
Be conservative in your estimates, since any money remaining in your accounts cannot be returned to you .
Health FSA Worksheet
Dependent Care Worksheet
Estimate your eligible, uninsured out-of-pocket medical
Estimate your eligible dependent care expenses for the plan
expenses for the plan year. IRS contribution limits for the
year. Remember that your calculated amount cannot exceed
health FSA are based on the plan year (July 1 - June 30), not
the calendar year limits established by the IRS.
the calendar year.
CHILD CARE EXPENSES
UNINSURED MEDICAL EXPENSES
Day care services
$ _________________
Health insurance deductibles
$ _________________
In-home care/au pair services
$ _________________
Coinsurance or co-payments
$ _________________
Nursery and preschool
$ _________________
Vision care
$ _________________
After-school care
$ _________________
Dental care
$ _________________
Summer day camps
$ _________________
Prescription drugs
$ _________________
ELDER CARE SERVICES
Travel costs for medical care
$ _________________
Day care center
$ _________________
Other eligible expenses
$ _________________
In-home care
$ _________________
TOTAL
TOTAL
(IRS contribution limit: Up to $2,550)
$ _________________
(IRS contribution limit: Up to $5,000,
depending on how your taxes are filed) $ _________________
DIVIDE by the number of paychecks
you will receive during your
DIVIDE by the number of paychecks
coverage period
÷ _________________
you will receive during your
coverage period
÷ _________________
This is your pay period contribution $ _________________
(whole dollar amounts only)
This is your pay period contribution $ _________________
(whole dollar amounts only)
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