Dependent Care FSA Worksheet

The following worksheet is provided to assist with the planning of your Dependent Care FSA contribution. Before making a decision, you may wish to review what you spent on dependent care last year.

First, estimate your total expenses. If you are enrolling during the open enrollment period, use the chart below to calculate your expenses for next calendar year. If you are joining the program during the year (that is, after the open enrollment period is over), use the chart to calculate your expenses for the remainder of the calendar year.

Remember, only those expenses for dependent care services that allow you and your spouse to work are eligible to be reimbursed through the Dependent Care FSA.

Type of Expense Amount
per Week		 X Number of
Weeks/Year		 = Total
for Year
Child Care Provider
Child Care Center
Nursery School
Before/After School Care
Summer Day Camp
Adult Day Care Center
Disabled Dependent Care1
Household Services2
Other Expenses
TOTAL ANNUAL EXPENSES
(MAXIMUM AMOUNT ALLOWED BY IRS: $5,000)

    


IRS regulations state that whether an expense is eligible or not will depend upon the facts and circumstances of each case.

1 Disabled dependent care is eligible regardless of whether it is provided inside or outside your home, as long as the dependent resides with you at least 8 hours a day.
2 Household services, such as a cook or housekeeper, are eligible if the services are provided, in part, to a person who qualifies as a dependent and are provided to enable you and your spouse to work.