UNREIMBURSED MEDICAL PLAN EMPLOYEE WORKSHEET
This worksheet will help you estimate your annual medical care costs, which may not be reimbursed by insurance. This list is not intended to be comprehensive, but it contains some of the more common medical expenses. List all costs that are not reimbursed by other coverage incurred by you, your spouse and/or qualified dependents:
Qualifying Medical Care Expenses
Estimated Annual Expense __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
Co-pays & Deductibles Annual Physical Examinations Dental Examinations Orthodontia Eyeglasses and Prescription Sunglasses Contact Lenses & Saline Solution Prescription Drugs X-rays Lab Fees Immunizations including Flu Shots Chiropractors Hearing Aids Over-the-Counter Drugs—NEW! Ambulance Service Medical Monitoring/Testing Devices (blood pressure monitor, glucose kit, etc.) False Teeth Insulin Lasik Eye Surgery __________________________________ __________________________________ __________________________________
TOTAL ESTIMATED ANNUAL EXPENSES NUMBER OF PAY PERIODS IN A YEAR (i.e. 24, 26 … AMOUNT OF REDUCTION PER PAY PERIOD (A/B)
(A) $ __________ (B) __________ $ __________
Medical Care Expenses Generally Not Allowed by the Law
§ § § § § § § § § § § § § § § § § § § § §
Controlled substances (Marijuana) Cosmetics Cosmetic surgery Ear Piercing Exercise equipment or fitness programs for general well-being Face Lifts; generally no. Funeral expenses Illegal operations or drugs Long-term care expenses Massage therapy; unless prescribed by a physician. Maternity Clothes Nursing care for a healthy baby Non-prescription drugs and medicines Rogain; not even if prescribed by a physician. Safety Glasses Swimming Lessons; not unless prescribed for a specific medical condition Tanning Salons Teeth Whitening Travel your physician told you to take for rest or change. Tuition; probably not unless primary purpose is medical care Vitamins; not unless accompanied by physicians certification
Qualifying medical expenses include only those expenses incurred for: § § § Yourself Your spouse. All dependents you list on your federal tax return.
DEPENDENT CARE ASSISTANCE PLAN EMPLOYEE WORKSHEET
This worksheet will help you estimate your dependent care assistance costs, which can be paid for with pre-tax dollars. This worksheet is not intended to be comprehensive but may be used as a guide. Please review the last section of this form for additional dependent care assistance information. Estimated Qualifying Expense Annual Amount
Amounts paid to a dependent care center (e.g., child day care) Amounts paid for dependent care services outside your home $ Amounts paid for dependent care services inside your home ________________________ ________________________ TOTAL DEPENDENT CARE ASSISTANCE NUMBER OF PAY PERIODS AMOUNT OF REDUCTION PER PAY PERIOD (A/B)
$
____________
____________ $ $ $ ____________ ____________ ____________
$ (A) ____________ $ (B) ____________ $ (C) ____________
An employee’s exclusion from income for payments under a DCAP in a calendar year is limited to the smallest of the following amounts: (a) $5,000 if the employee is married and filing a joint return or if the employee is a single parent ($2,500 if the employee is married, but filing separately); the employee’s earned income; If the employee is married at the end of the taxable year, the spouse’s earned income*
$ ________ (a) $ ________ (b)
(b) (c)
$ ________ (c)
*For purposes of (c) above, your spouse will be deemed to have earned income of $200 ($400 if you have two or more dependents), for each month in which your spouse is (i) physically or mentally incapable of caring for himself or herself, or (ii) a full-time student at an educational institution.
QUALIFYING DEPENDENT CARE EXPENSES
Under the plan, you will be reimbursed only for dependent care expenses meeting all of the following conditions:* 1. Your expenses are incurred for services rendered after the date of your election and during the plan year to which it applies. 2. Each individual for whom you incur the expenses is a dependent for income tax purposes and: a.) Is 12 years of age or younger, or; b.) Is a spouse, parent or other dependent who is physically or mentally unable to care for himslef or herself (must live at least 8 hours per day in employee’s household) 3. Your expenses are incurred for the care of a dependent described above, or for related incidental household services, and are incurred to enable you to be gainfully employed. 4. If you expenses are incurred for services outside your household, they are incurred for the care of a dependent who is described in (2) above, or who regularly spends at least 8 hours per day in your household. 5. If you expenses are incurred for services provided by a dependent care center (i.e., a facility that provides care for more than seven individuals not residing at the facility), the center must comply with all applicable state and local laws and regulations. 6. Your expenses are not paid or payable to a child of yours who is under age 19 at the end of the year in which the expenses are incurred. 7. Payments to someone whom the employee (or the employee’s spouse) could claim as a dependent for federal income tax purposes are not eligible for the tax credit. In addition, such payments are not reimbursable under a DCAP. 8. You will want to decide whether or not to claim the dependent care tax credit for eligible dependent care expenses, participate in a DCAP, or (as permitted in a few instances) both. To calculate the dependent care tax credit for 2003, an employee may take into account only $3,000 of employment-related childcare expenses for one dependent, or $6,000 for two or more dependents. The amount of the savings with the tax credit will depend on the taxpayer’s income, and it ranges from 20% to 35%. An employee with two or more qualifying individuals who incurs $6,000 of eligible expenses (and who receives the maximum $5,000 DCAP benefits) may be able to claim an additional credit in an amount equal to a percentage of $1,000. (Employees cannot, however, claim the same expense under both the tax credit and the DCAP —there’s no “double dipping” allowed.) Although for most taxpayers the DCAP will provide the greater tax benefit, sometimes the credit produces greater tax savings, depending on factors unique to each employee—such as total income, filing status, salary reduction amounts, the number of qualifying individuals, and the amount of dependent care expenses. Please ask your Administrator for a DCAP vs. Dependent Care Credit Comparison Worksheet to help determine your individual tax position.