Dependent Care FSA Claim Form - ADP Flexible Spending Accounts 2026

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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 for dependents, necessary steps to complete the form, required supporting documentation, and submission methods. Additionally, it emphasizes IRS regulations regarding substantiation of expenses and includes definitions of qualifying children and relatives. The document also offers contact information for further assistance.

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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. For each expense, provide the start and end dates of service, requested amount, provider's tax ID or SSN, and confirm if a receipt is attached. Remember to complete a separate line for each individual expense.
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 ADP. If you provide an email address, you will receive confirmation of receipt.
Opt for Direct Deposit for faster reimbursement processing. Log into your account at myspendingaccount.adp.com to set this up.

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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?

In addition, your plan participants (and even nonparticipants) can access ADPs FSA and Commuter Benefits Web site and perform tasks to learn more about the plans, find answers to common questions, download forms, and view account activity.

What is dependent care flexible spending account (FSA)?

A Dependent Care FSA (DCFSA) is used to pay for childcare or adult dependent care expenses that are necessary to allow you and your spouse, if married, to work, look for work or attend school full-time.

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 file a claim for dependent care in FSA?

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.