Dependent Care FSA Claim Form - ADP Flexible Spending Accounts 2025

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The document provides a detailed guide on how to request reimbursement for dependent care expenses through a specific form. It outlines eligibility criteria, necessary documentation, and submission procedures, including the importance of itemized receipts and compliance with IRS regulations. The document emphasizes the need for accurate completion of the form and offers instructions for both faxing and mailing submissions.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out Section 1 with your personal information, including your Social Security Number or Employee ID, company name, and contact details. Ensure you use capital letters and center your text within the boxes.
In Section 2, list each dependent care expense separately. Fill in the start and end dates of service, requested amount, provider tax ID or SSN, and indicate if a receipt is attached. Repeat this for each expense on separate lines.
Attach supporting documentation by copying receipts onto a white sheet of paper. Write your Social Security Number or employee ID at the top and ensure all receipts face the same direction.
Submit your completed form either by faxing it along with the receipts or mailing it to the provided address. If you include your email address, you will receive confirmation from ADP.
For faster reimbursement, consider signing up for Direct Deposit through myspendingaccount.adp.com.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Does ADP offer FSA accounts?

ADPs experienced administrators are dedicated exclusively to servicing FSA participants with tested and proven FSA administration practices and systems.

How do I report dependent care FSA on my taxes?

You must file Form 2441 with your return if you have a dependent care FSA.

How do I report dependent care FSA on W-2?

When you are eligible to participate in a dependent care assistance program through your employer and you choose to participate, your employer has to report that value in box 10 of your Form W-2.

How do I claim dependent care flexible spending account?

You can submit a claim via the WEX mobile app, online or by mail. To submit a claim through the mobile app, download the Benefits by WEX app [PDF] from the App Store or Google Play. Then log in to your account via the app, select File a Claim and follow the steps.

What are box 14 codes on W-2?

W-2 box 14 codes list CodeDescription CC Designated Roth contributions under a section 457(b) plan DD Cost of employer-sponsored health coverage EE After-tax contributions to a Roth 401(k) plan FF After-tax contributions to a Roth 403(b) plan15 more rows

How do I submit a receipt for dependent care FSA?

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

How is dependent care FSA reported on W-2?

Box 10 of your W-2 shows the total amount of dependent care benefits that your employer paid to you or incurred on your behalf.

Does dependent care FSA count as income?

Employers have the option to set a limit lower than the amounts listed, but not in excess. Any contributions to a dependent care FSA that exceed the imposed limit during a calendar year are treated as taxable income.

Dependent Care FSA Claim Form - ADP Flexible Spending Accounts 2025

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