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Click ‘Get Form’ to open the ADP Dependent Care FSA Claim Form in the editor.
Complete all Employee Information fields. Enter your name in ALL CAPITAL letters, your employer’s name, mailing address, daytime phone number, and your 10-digit FlexID.
Fill out the Expense Information section. Include one Claim Service Period per line. Ensure that the beginning and ending dates match your receipts, if available.
If you do not have receipts, have your Dependent Care Provider certify the expenses by signing where indicated.
Sign and date your Claim Form. Claims without a signature cannot be processed.
Submit your completed form by faxing it to 866-392-4090 for the fastest processing or mail it to ADP Claims Processing.

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What kind of receipt do I need for dependent care FSA?

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.

How to submit claim for dependent care in FSA?

Supporting documentation for your claim should be an itemized statement from the dependent care provider that includes: service date(s), the dependents name, the type of service, amount billed, and providers name and address. You may not submit a canceled check as supporting documentation.

How long does it take to submit a dependent care FSA claim?

Important Timelines: Employees have 120 days after the end of the Plan Year to submit claims for dependent care expenses. A terminated employee has 120 days from date of termination to submit claims for eligible daycare expenses incurred prior to the termination date.

How to submit dependent care FSA claim?

Dependent Care FSA Use the FSAFEDS app to have the dependent care provider docHub the service by providing a signature on your mobile device. Have the dependent care provider docHub the service by signing the completed claim form (PDF). Submit a claim (PDF) with an itemized statement from the dependent care provider.

How do you use dependant care in FSA?

With a Dependent Care FSA, you use pre-tax dollars to pay qualified out-of-pocket dependent care expenses. The money you contribute to a Dependent Care FSA is not subject to payroll taxes, so you end up paying less in taxes and taking home more of your paycheck.

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