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HEALTH CARE SPENDING ACCOUNT REIMBURSEMENT REQUEST FORM SECTION A ENROLLED NAME STREET ADDRESS PLAN YEAR SOCIAL SECURITY NUMBER DAYTIME PHONE AREA CODE NUMBER EXT. CITY STATE ZIP CODE SECTION B SUMMARY.

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An entry of code "W" in box 12 of your W-2 indicates to the IRS that you have an HSA. The FSA deductions are reported either in box 10 (for a dependent care FSA, as in your case) or in box 14, as information for the taxpayer for other types of FSAs.

The funds in your Medical and Dependent Care FSA are deposited pre-tax and the amount is deducted from your Annual Gross Income. This will be represented on the W-2 you receive from your Employer for tax reporting. There are no additional tax forms issued for the FSA plans.

A health FSA may receive contributions from an eligible individual. Employers may also contribute. Contributions aren't includible in income. Reimbursements from an FSA that are used to pay qualified medical expenses aren't taxed.

A flexible spending arrangement (FSA) allows employees to get reimbursed for medical or dependent care benefits from an account they set up with pre-tax dollars. The salary-reduction contributions are not included in your taxable wages reported on Form W-2.

There is no 1099-SA form or other tax statement for the Flexible Spending Account (FSA), which is different from the Health Savings Account (HSA). FSA funds are already tax-free and not needed for tax purposes.

If you are eligible to enroll, you may contribute any amount from $100 up to $2,750 annually in pre-tax dollars to pay for health care expenses that are not reimbursed by health insurance or other benefit plans.

A Flexible Spending Account (FSA) is an employee benefit that allows you to set aside money, on a pre-tax basis, for certain health care and dependent care expenses. There are three types of FSA accounts: 1) Health Care FSA (HCFSA); 2) Limited Expense Health Care FSA (LEX HCFSA); and 3) Dependent Care FSA (DCFSA).

Submit Your Claim in One of These Ways Log in to your account. ... Once you have logged into your account, click Submit Receipt or Claim and select your Reimbursement Option. Follow the step-by-step instructions. Upload digital copies of your itemized receipts (and other documentation if needed).

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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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
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
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