Dependent Care FSA claim form - City of Austin: Fill out & sign online

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Click ‘Get Form’ to open the Dependent Care FSA claim form in our editor.
Begin with Section I. Fill in your last name, first name, middle initial, address, city, state, zip code, and phone numbers. Ensure you include the provider's name and tax ID number.
List the names and ages of your dependents along with the dates of service for which you are claiming reimbursement. Enter the total work-related dependent care charges.
In Section II, if your provider cannot sign the form, attach an original itemized receipt or statement as documentation. If they can sign, ensure their signature and date are included.
Complete Section III by certifying that all expenses qualify for reimbursement under IRS guidelines. Sign and date this section to validate your claim.
Once completed, print the form and submit it along with any required documentation to the specified address or fax number provided.

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What documentation is needed for dependent care FSA?

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 to submit claim for dependent care in FSA?

If you participate in a dependent care FSA by WEX, you have two easy options for collecting reimbursement with this type of FSA: Mobile or online reimbursement. You can easily upload documentation to a claim by logging into our mobile app, taking a photo of your documentation with your phones camera and uploading it.

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.

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.