Fillable Fsafeds Dependent Care Fsa Claim Form (Page 2 of 3) in pdf

MAIL: FSAFEDS Program

DEPENDENT CARE CLAIM FORM

PO Box 36880

Use only CAPITAL LETTErS

Louisville, KY 40233

ZBXDKPV

FAx TO: 1-866-643-2245 TOLL-FrEE or 1-502-267-2233

PHONE: 1-877-FSAFEDS

For additional expenses, please use next page.

(1-877-372-3337)

TTY:1-800-952-0450

SECTION 1: EMPLOYEE INFORMATION

PrOGrAM nAME

FOr SHPS USE

EMPLOYEE USEr ID (nO DASHES)

FSAFEDS

EMPLOYEE LAST nAME

EMPLOYEE FIrST nAME

DAYTIME PHOnE # (ArEA CODE FIrST, nO DASHES)

EMPLOYEE EMAIL

SECTION 2: YOUR DEPENDENT CARE EXPENSES

EXPENSE 1

STArT DATE OF SErvICE (MMDDYY)

PrOvIDEr TAx ID Or SSn (EnTEr ALL 9’S IF TAx-ExEMPT)

AMOUnT rEqUESTED (DOLLArS . CEnTS)

EnD DATE OF SErvICE (MMDDYY)

DEPEnDEnT DATE OF BIrTH (MMDDYYYY)

ExPEnSE 1 COvErS:

DEPEnDEnT nAME

AFFIDAvIT:

Your daycare provider only needs to sign this if you do not have supporting documentation, such as an itemized receipt.

I hereby certify that I provided adult or child daycare services to the above individuals in accordance with the amounts and dates that

are requested.

PrOvIDEr’S SIGnATUrE

DATE

TOTAL REQUESTED (SUm Of EXPENSES fROm ALL PAgES SUbmiTTED)

SECTION 3: CERTIFICATION

Please read carefully before signing.

I affirm that:

0.00

• I HAvE nOT ALrEADY BEEn PAID FOr THESE ExPEnSES FrOM MY FSA and I HAvE nOT rEqUESTED AnD WILL

nOT rECEIvE rEIMBUrSEMEnT FOr THESE ExPEnSES FrOM AnY OTHEr PLAn; AND

• I have submitted the above information in good faith and it is correct to the best of my knowledge.

• The total of any reimbursed dependent care expenses does not exceed my or my spouse’s earned income (W-2 Pay) for the year, if either of our annual incomes are less than $5,000.

I understand that:

• reimbursement is not a guarantee that this payment is tax-free.

• The service(s) for which I am requesting reimbursement must be incurred during my period of coverage, which begins the next January 1 if I enrolled during the Open Season,

or the day after my enrollment is accepted by FSAFEDS, whichever is later, and ends no later than March 15 of the following year, unless my coverage ends sooner due to a

qualifying Life Event.

• I have until April 30 following the end of the Benefit Period or end of Federal Service to submit my claim for reimbursement of eligible expenses incurred during my period

of coverage. If I do not submit claims for reimbursement by that date, I will forfeit any funds remaining in my account in accordance with IRS rules.

• I cannot use dependent care expenses reimbursed through my Dependent Care Flexible Spending Account (DCFSA) as a dependent care credit on my personal income tax return.

Therefore, reimbursement of dependent care expenses reduces, and may eliminate completely, my ability to claim a dependent care credit on my personal income tax return.

• I am submitting dependent care claims for my dependent child(ren) under age 13 and/or for my age 13 or over dependents who are physically or mentally incapable of

caring for themselves and includes anyone I claim on my Federal Income Tax return as a qualified IRS dependent.

• Dependent care expenses (including overnight day care expenses) must be incurred so that my spouse and I, if married, can work, look for work or my spouse can attend

school full-time.

• My household limit for dependent care reimbursement cannot exceed $5,000 per year, including my annual election, any child care subsidies that I receive, and/or amounts that my

spouse has elected through another account.

• The balance in my DCFSA must be at least equal to the expenses submitted with this claim. If the balance in my DCFSA is less, these expenses will be held until the balance in my

account is sufficient to pay these expenses.

• I can only be reimbursed for my DCFSA expenses after the date of service has passed.

I authorize FSAFEDS, or its representatives, to obtain necessary information from dependent care providers, employers, and all other agencies or organizations to consider the claim for

reimbursement under my Flexible Spending Account; and to release payment through my Flexible Spending Account.

Employee Signature*

Date

(MMDDYY)

* Your signature and date are required in order to process your claim for reimbursement.

ZBXDKPV

USE An OrIGInAL FOrM (nOT A PHOTOCOPY)

Page 2 - DEPENDENT CARE CLAIM FORM