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  • Flexible Spending Dependent Care Claim Form - Sanford Health - South Sanfordhealth

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Sioux Valley Health Plan P.O. Box 91110 Sioux Falls, SD 57109-1110 (605) 328-6810 / Fax: (605) 328-7207 www.svhp.com Flexible Spending Dependent Care Claim Form IMPORTANT NOTE: This form MUST be completed.

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For 2022, the credit for child and dependent care expenses is nonrefundable and you may claim the credit on qualifying employment-related expenses of up to $3,000 if you had one qualifying person, or $6,000 if you had two or more qualifying persons. The maximum credit is 35% of your employment-related expenses.

Once you have paid for expenses that qualify for reimbursement from the FSA, you will need to complete a claim form provided by your employer and attach receipts or proof of payment with the form. The receipts must include specific information to prove that the payment was for qualified expenses.

Any benefit-eligible faculty or staff member—regardless of the medical plan they are enrolled in—may use a Dependent Care FSA for child/day care expenses. You must enroll in a Dependent Care FSA separately from a Health Care FSA.

It is actually not an either/or decision. You can take advantage of both the DCFSA and Dependent Care Tax Credit. But, you cannot double-dip.

About Form 2441, Child and Dependent Care Expenses.

Offered through your employer, a dependent care FSA, can help you put aside dollars income tax- free for the care of children under 14 or for dependent adults who can't care for themselves. Each household can contribute up to the IRS-allowed maximum. Your account is funded by payroll deductions before taxes.

Maximum Annual Dependent Care FSA Contribution Limits If your tax filing status is Single, your annual limit is: $5,000 if your 2022 earnings were less than $135,000; however, your contributions may not be in excess of your earned income for the plan year. $3,600 if your 2022 earnings were $135,000 or more.

The difference between a Health Care FSA and a Dependent Care FSA is that the Health Care FSA is for eligible health care expenses for you and your eligible dependents, and the Dependent Care FSA is for expenses related to the care of a dependent child or adult (for example, day care). The two are NOT interchangeable.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232