Dependent Care Claim Form 2015
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1
2Dependent Care Claim
Flexible Spending Account
Certification Form
Email:
Cafeteria Plan Advisors, Inc.
Phone: 781-848-9848
420 Washington Street, Suite 100
FAX: 781-848-8477
Braintree, MA 02184
e
Plan Year:
Employee Name:
Employer:
XXX-XX-
SSN (Last four)
Mailing Address:
Participant Phone:
City, State, Zip:
Email:
Check if New Address
Eligible Dependents:
The dependent care expenses must be employment related. Dependents eligible for FSA funding:
-Must be under age 13
-Physically or mentally incapacitated
-Reside with Participant
-Qualify as Dependent under IRS code section 151(c)
-Earn less than $3800 per year unless qualifying child
Dependent Information:
Dependent Name
Relationship
Date of Birth
Dependent Name
Relationship
Date of Birth
Day Care Facility or Individual who provides care:
Name:
Name:
Address:
Address:
Corporate or Individual Tax ID (Required):
Corporate or Individual Tax ID(Required):
__________________________
______________-______________
Claim Amount: $
Dates of Service:
Beg
End
This is to certify that I, the undersigned, have incurred expenses that qualify under IRC section 129 “Dependent Care Assistance
Programs.” I have not been, and will not be reimbursed for these expenses by any source, including, but not limited to, insurance, this
plan, or other programs offered by my, or my spouses, employer. I understand these expenses may no longer be claimed as deductions
for income tax purposes since I am requesting reimbursement with funds deducted from my compensation on a pre-tax basis. The
undersigned reaffirms that all eligibility criteria set forth by the IRS, found on the reverse side of this form and at ,
continue to be met at the time these dependent care expenses were incurred. I acknowledge that I am solely liable for any taxes or
penalties on ineligible expenses processed through the dependent care plan. I, and only I, am responsible for the accuracy and validity of
the submitted expenses. It is my responsibility to retain ALL receipts. I hereby authorize Cafeteria Plan Advisors, Inc. to reimburse me for
the “Claim Amount” listed above, and, if applicable, reaffirm the authorization provided to Cafeteria Plan Advisors, Inc. to directly
deposit the reimbursement into my bank.
PARTICIPANT’S SIGNATURE:
DATE:
Return page 1 via mail, fax, or email to
Rev. 4-2015
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