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S and I certify that the expenses itemized below and claimed by me for reimbursement qualify under the plan rules. I also understand that expenses claimed for reimbursement may not be claimed as deductions on individual income tax returns. Instructions: You will make your dependent day care payments directly to the provider. Secure a signed receipt for each payment made. You must attach your receipt to a completed and signed Request for Reimbursement Form. Receipts must include the period of tim.

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Remember, to be accepted for a claim, you'll need one of the two accepted forms of paperwork: an itemized receipt, or an Explanation of Benefits (EOB) form (which is typically used for eligible medical services).

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 Claim Form must be completed entirely, dated and signed. Receipts must state the provider name, provider contact information, the dependent name, service dates (begin and end), a description of the service and the expense amount. A credit card receipt or canceled check is not adequate documentation.

For payments to merchants, include an application showing the amount to be paid or an invoice. For reimbursements to employees, include an application or invoice from the merchant with proof of payment.

To claim the credit, you (and your spouse, if you're married) must have income earned from a job and you must have paid for the care so that you could work or look for work. You can claim from 20% to 35% of your care expenses up to a maximum of $3,000 for one person, or $6,000 for two or more people (tax year 2023).

The Claim Form must be completed entirely, dated and signed. Receipts must state the provider name, provider contact information, the dependent name, service dates (begin and end), a description of the service and the expense amount. A credit card receipt or canceled check is not adequate documentation.

Box 10 on your W-2 form should indicate the total annual amount of your Dependent Care FSA deductions. When completing your tax return, you will need to attach a Child and Dependent Care Expenses form (Form 2441 for a 1040 return; Schedule A for a 1040A return).

With dependent care FSAs, you pay expenses out of pocket, then receive reimbursement based on how much you have withheld from your paycheck for dependent care expenses. Before setting up a dependent care FSA, compare its potential tax benefits with the child and dependent care tax credit.

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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
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