Personal Expenses Worksheet Template

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Island Flex
Island Flex
Island Flex
Island Flex
Island Flex
Personal Expenses Worksheet
You can use this worksheet to estimate your expenses. The items listed are not the only ones you can reimburse
through your Island Flex flexible spending account(s), but they are the most popular.
FOR THE PERIOD __________________ TO _____________________
MEDICAL EXPENSES
Include out-of-pocket costs for yourself, your spouse (if married),
and all of your dependents.
Chiropractic, acupuncture, shiatsu, etc.
$
Co-payments for doctor/dental visits
$
Co-payments for hospital services
$
Dental, including dentures
$
Drugs (prescribed medicines, contraceptives)
$
Lab and x-ray tests
$
Orthodontics
$
Parking fees while you visit the doctor
$
Routine physicals and well-baby visits
$
Smoking cessation program
$
Vision (optometry visits, prescription glasses,
contacts, contact solutions)
$
Other eligible medical expenses
$
Total Medical Expenses
$
DEPENDENT CARE EXPENSES
Expenses incurred for the care of a dependent in order for you (and your spouse)
to be gainfully employed. Your care provider must provide a Federal I.D.
number or Social Security number.
Baby-sitting
$
Preschool/child care
$
Before/after school care
$
Programs during non-school periods
$
Certain types of care for an incapacitated
dependent over 12 years
$
Other eligible dependent care expenses
$
Total Dependent Care Expenses
$
State of Hawaii

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