You may want to review receipts from last year for health care expenses you paid out of your own pocket. Using these receipts and the worksheet, you can estimate the amount you want to elect for the Health Care FSA. Only budget for the expenses eligible for reimbursement though the Health Care FSA. Remember, eligible expenses include those for you, your spouse and your dependents. Deductibles Medical, dental, vision Copayment / Coinsurance The amount not paid by your health plan coverage Expenses NOT covered by insurance plan Prescription drugs Vision care Dental/orthodontic care Medical equipment Other eligible expenses (Click here for a list)   Out-Of-Pocket Health Care Expenses This gives you a good idea of the amount you should elect to place into your Health Care FSA. Consider any other factors that will affect your out-of-pocket health care costs during the upcoming plan year, and adjust the amount if necessary.   Savings Through Use of Pre-Tax Premiums How much do you contribute on a monthly basis toward your employer sponsored health insurance plan. * - Pre-tax premiums are separate from FSA deductions and may not be reimbursed through FSA.     Individual Dependent Care FSA Worksheet The Dependent Care FSA allows you to use pre-tax dollars to pay for child care services that make it possible for you and your spouse (if applicable) to work. Under certain circumstances it also may be used to help pay for the care of elderly parents or a disabled spouse or dependent. Note that the Dependent Care FSA is intended to cover costs of care and does not cover any medical or health-care costs for your dependents.     Child Care Expenses Day Care Center In-home Care Nursery and Pre-school After school Care Au Pair Services Summer Day Camps                 Elder Care Services Day Care Center In-home Care       Out-Of-Pocket Dependent Care Expenses This total gives you an estimate amount that you should elect to place into your Dependent Care FSA. Remember, you'll escape Social Security and Medicare taxes on the money you set aside. Choose the state in which you work: --Select a State-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Select appropriate marital status: --Select-- Single Married Please enter your approximate household annual income before taxes: How often do you get paid per year?   Answers: Based on the previous calculation sheet your annual unreimbursed medical expenses are: Answers: Based on the previous calculation sheet your portion of your health insurance a year equals:    Based on the previous calculation sheet your annual unreimbursed dependent care expenses are:    Based on the annual income, average state tax rate, and marital status your tax rate is: Based on the accuracy of your above selections, your tax savings would be:    Based on this selection, your pay period contribution would be:    EMPLOYEE TAX SAVINGS WITHOUT FSA WITH FSA Gross Monthly Wages Dependent Care FSA   Medical Care FSA   Premium Conversion   Taxable Monthly Wages Income Taxes Dependent Care FSA   Medical Care FSA   Premium Conversion   Spendable Income Monthly Tax Savings Annual Tax Savings / Spendable Income * *Tax Saving examples are based on the numbers you provide. Payroll and income tax laws vary from state to state. Savings may be greater or lessor depending on individual tax brackets, state income tax rates and the accuracy of the information you have supplied.

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