HealthCare Flexible Spending Account Worksheet by parpar

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									          HealthCare Flexible Spending Account Worksheet
          Estimate Your Deposit
          Below you will find a worksheet to help you estimate your deposit to the health care
          FSA. Think about your annual out-of-pocket health care expenses, then look at the list
          and write in estimated out-of-pocket costs for the upcoming year. Your maximum annual
          deposit is $6,500.00

                   Medical                                  Dental                                  Vision

                      Actual     Estimated                   Actual      Estimated                   Actual     Estimated
   Types of                                   Types of                                 Types of
                     Expenses    Expenses                   Expenses     Expenses                   Expenses    Expenses
   Expenses                                   Expenses                                 Expenses
                     This Year   Next Year                  This Year    Next Year                  This Year   Next Year

Deductibles         $_______     $_______    Deductibles    $_______     $_______     Deductibles   $_______    $_______

Co-pays             $_______     $_______    Co-pays        $_______     $_______     Co-pays       $_______    $_______

Co-insurance        $_______     $_______    Co-insurance   $_______     $_______     Co-           $_______    $_______
                                                                                      insurance
Expenses not        $_______     $_______    Expenses       $_______     $_______
covered or not                               exceeding                                Eyeglass      $_______    $_______
covered in full,                             plan                                     Frames
such as doctor                               maximums
fees                                                        $_______     $_______     Eyeglass      $_______    $_______
                                             Orthodontia                              Lenses
Prescriptions       $_______     $_______                   $_______     $_______
                                             Other                                    Contact       $_______    $_______
Over the            $_______     $_______                                             Lenses
Counter Drugs                                                                                       $_______    $_______
                                                                                      Other
Hospital Costs      $_______     $_______

Mental Health       $_______     $_______
Services
                                 $_______
Wellness Care       $_______
Other


Totals              $_______     $_______    Totals         $_______     $_______     Totals        $_______    $_______



                                       Medical + Dental + Vision        TOTAL        $__________________

                        Divided by the number of pay periods in the year             $__________________

                                   Equals your per paycheck contribution             $__________________
Dependent Care Flexible Spending Account Worksheet
Estimate Your Deposit
Dependent day care expenses are often easy to predict. Just think about what you spent
last year and whether or not you expect to spend about the same amount in the
upcoming year. To help you estimate your dependent day care expenses, use the
worksheet below. Remember to include only those dependent care expenses you have
so that you can work. If you are married, the expense must be necessary so that both
you and your spouse can work, or so that your spouse can attend school full-time.



                                          Actual Expenses           Estimated Expenses
           Type of Expense
                                             This Year                   Next Year


  Day Care Center                     $ ______________________    $ ____________________

  Babysitter while you are at work    $ ______________________    $ ____________________

  Nursery School or Preschool         $ ______________________    $ ____________________

  After-school care                   $ ______________________    $ ____________________

  Before-school care                  $ ______________________    $ ____________________

  Summer camp (not overnight)         $ ______________________    $ ____________________

  Housekeeper whose duties
  include day care                    $ ______________________    $ ____________________

  Licensed Home Healthcare            $ ______________________    $ ____________________
  Provider

                                     $________________________   $______________________
  Totals

                                                      TOTAL $__________________

           Divided by the number of pay periods in the year $__________________

                       Equals your per paycheck contribution $__________________

								
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