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Click ‘Get Form’ to open the decap form in the editor.
Begin by filling out the EMPLOYEE (PARTICIPANT) INFORMATION section. Clearly type or print your last name, first name, home address, email address, and phone numbers. Ensure all details are accurate.
In the DeCAP REIMBURSEMENT REQUESTS section, list each dependent's name and provide the dates of service for which you are requesting reimbursement. Make sure these dates are prior to when you sign the form.
For each service provided, specify the type of service and the reimbursement amount requested. Include the provider’s name and address along with their federal tax ID or social security number.
Finally, sign and date the form in the EMPLOYEE (PARTICIPANT) SIGNATURE section. If you cannot sign electronically, typing your name will suffice.
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How do I submit a Federal Flexible Spending Account Program (FSAFEDS) online claim? You can submit your claim online by logging into My Account Summary at .FSAFEDS.com , clicking on My Claims, and selecting Online Claim Submission. You must upload an image of your supporting documentation in .
How do I submit my FSA claim?
Youre receiving a tax benefit because under the plan, youre not paying taxes on the money set aside to pay for the dependent care expenses. You must complete and attach Form 2441, Child and Dependent Care Expenses to your tax return.
Do I need to claim my FSA on my taxes?
If I participated in a Health Care FSA, do I need to report anything on my personal income tax return at the end of the year? No. There are no reporting requirements for Health Care FSAs on your income tax return.
What is a DCAP form?
San Bernardino County offers a Dependent Care Assistance Plan (DCAP) that allows you to take a pre-tax deduction from your income to pay for eligible dependent care expenses as an alternative to taking the Dependent Care Tax Credit (DCTC).
Do I need to submit receipts for FSA?
The service documentation will need to include: Provider Name Service Dates (not payment date) Patient Name Type of Service Out- of-Pocket Cost or Your provider may sign the form confirming the date of services, charges and other service or product information in lieu of providing separate documentation or
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This form is to be completed by your provider after dependent care expenses have been incurred and should be used in place of dependent care documentation. Attach this form to an online or debit card claim via your online account or to a Claim Form.
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fsa-forms-and-downloads
3) Forms/documents can be submitted electronically to: . Plan Year 2025. 2025 DeCAP Claims Form 2025 HCFSA Claims Form. Lost Check
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