VIEWS: 27 PAGES: 6 POSTED ON: 6/3/2010
FLEXIBLE SPENDING ACCOUNT CLAIM FORM READ THE INSTRUCTIONS ON THE BACK OF THIS FORM BEFORE COMPLETION FOR ADDITIONAL INFORMATION AND TO AVOID ANY ERRORS OR DELAYS IN PROCESSING Name __________________________________________________________________________________________ Last First SS# _________________________________________________________________________________________________ Address City, State Zip Employer Name HEALTH CARE ELIGIBLE EXPENSES DESCRIPTION OF DATE OF TOTAL AMT AMT PAID BY YOUR COST EXPENSES FOR: NAME (AND IF ELIGIBLE EXPENSE EXPENSE OF BILL ANY PLAN (CLAIM AMOUNT) DEPENDENT, RELATIONSHIP & DOB $ $ $ $ TOTAL $ DEPENDENT CARE ELIGIBLE EXPENSES FED ID# OR SS# OF DATES OF CARE EXPENSES FOR: CARE PROVIDER NAME TOTAL AMOUNT CARE PROVIDER FROM - TO NAME, RELATIONSHIP & DOB $ $ $ $ TOTAL $ I certify that these expenses were incurred by me and/or my eligible dependents. I further certify that these expenses are not reimbursable under any other plan, including a plan of another employer that covers me, my spouse or another member of my fam ily. I understand that I cannot use expenses reimbursed through this account as deductions when filing my individual income tax return. I understand that if I do not provide required documentation, I will not be reimbursed. I authorize my employer to deduct the total amount requested from my account in accordance with the terms and provisions of the Flexible Spending Account plan. If I receive reimbursement for health care expenses that are not eligible, I agree on demand to indemnify and reimburse my employer for an y liability I may incur for failure to withhold income tax or Social Security tax up to the amount of additional tax actually owed by me. _______________________________________ ATTACH COPIES OF BILLS/RECEIPTS AND MAIL OR FAX TO: Employee Signature ADMINPRO, INC. __________________ 1423 E 11 Mile Road Date ROYAL OAK, MI 48067 TEL (248) 543-2644 FAX (248) 543-2296 INSTRUCTIONS FOR FILING A CLAIM 1. Please type or print all information clearly and submit claim form to: AdminPro, Inc., 306 S. Washington Ave., Suite 214, Ro yal Oak, MI 48067. Keep a copy of the claim form for your records. You may call AdminPro at (248) 543-2644 with any questions regarding your claim. 2. Attach copies of itemized bills or receipts to the claim form (You keep the originals). Canceled checks are not accepted. 3. You may only submit expenses incurred by you or your eligible dependents (as defined by the Internal Revenue Service). st 4. Claims will be accepted until March 31 of the following year for expenses incurred in the current calendar year. 5. Flexible spending account claims are processed and paid with your regular pay check. 6. Remember, disbursements from your spending accounts are made on a pre-tax basis. When filing your annual income tax return, do not declare reimbursements as income and do not take any expenses you have been reimbursed for as a deduction. 7. Carefully review the following list of eligible expenses, also detailed in the BeneFLEX enrollment guide. DESCRIPTION OF ELIGIBLE FLEXIBLE SPENDING ACCOUNT EXPENSES PLEASE READ CAREFULLY The Internal Revenue Service (IRS) has established the following types of expenses as eligible to be reimbursed from health and dependent care spending accounts. This list is not inclusive and is subject to change by the Internal Revenue Service and your employer. Health Care Expenses Exclusions Medical and dental plan deductibles and co pays Expenses for non-prescription drugs Out-of-pocket vision care expenses Athletic club expenses and exercise equipment Health care expenses not covered by a medical or dental Weight reduction or smoking cessation programs plan, such as routine exams, hearing aids, orthodontia, or Expenses incurred by persons other than yourself, your charges in excess of the benefit plan coverage current spouse and your eligible dependents Expenses not allowed by the Internal Revenue Code as eligible for income tax deduction Dependent Care Expenses Exclusions Eligible dependents are: Transportation expenses incurred while delivering dependent o Children under age 13 to care site o Spouse or child over 13 unable to care for Cost of care rendered by employee’s own child (18 or himself/herself younger), spouse or other dependent o Dependents such as parents, siblings, in-laws, etc. (not in a nursing home) incapable of self- care Eligible expenses are: o Licensed day care center costs o School costs for children below kindergarten Eligible circumstances are: o Care given while both parents are gainfully employed (or one parent in a single parent family) o In case of divorce or separation, only the parent with custody of the child can submit expenses Preferred Solutions, Inc. Flexible Spending Accounts Plan Facts Health Care Reimbursement Accounts Dependent Care Reimbursement Accounts Effective December 1, of every year, you have the opportunity to participate in the Preferred Solutions, Inc. Flexible Spending Accounts Plan which include a Health Care and/or Dependent Care Reimbursement Accounts. These are benefit plans that can help you manage your out-of- pocket expenses and also realize Federal, State and Social Security tax savings. As a participating employee, you can expect to realize an average tax saving of 30% on your annual contributions to the plans. Reimbursement Accounts are benefit options that allow you to direct a portion of your pay on a pre- tax basis into Accounts that can be used throughout the year to pay certain out-of-pocket health care and/or dependent care expenses. In other words, money that goes into your Reimbursement Account(s) is taken from your paycheck before Federal, State and Social Security taxes are withheld, so you reduce both your taxable income and the amount you pay in taxes each year. You then use the tax free dollars from the Reimbursement Account(s) to pay for eligible expenses. Health Care Reimbursement Accounts The Health Care Reimbursement Account operates on a plan year basis. Each year you decide whether to participate in the Health Care Reimbursement Account. Then you estimate the amount of eligible expenses you and your dependents will likely incur, and from this amount, determine how much you would like to set aside in the Health Care Reimbursement Account. What types of expenses are eligible? Most expenses that are not covered by the health benefit plan can be submitted for reimbursement. For example, you may elect to enroll in a health plan option that contains an annual deductible. If so, consider depositing money in the Health Care Reimbursement Account so you can be reimbursed for the deductible with tax-free dollars. If you believe you will incur out-of-pocket expenses because of a medical plan options' coinsurance feature, then consider depositing funds into the Health Care Reimbursement Account so you can be reimbursed for your coinsurance with tax-free dollars. Again, this determination must be made prior to the beginning of the Plan Year. There are many related expenses that you incur which can be reimbursed with tax-free dollars. Below is a partial list: Medical/Dental/Vision Plan Deductibles/Coinsurance and Office/Prescription Co-pays Over the counter remedies for injury or illness Cosmetic Surgery(Medically Necessary) Birth Control Pills Preventive and Routine Physicals for Adults Preventive Care and Immunizations for Children Mileage to and from Doctor's Office (.22 per mile) Contact Lenses/Prescription Eyeglasses/Vision Exams Psychotherapy Expenses Alcohol/Drug Treatment Chiropractor's Fees and Physical Therapy Fees Orthodontic (Braces) Fees Lasik eye surgery Dependent Care Reimbursement Accounts The Dependent Care Reimbursement Account reimburses you for eligible dependent care expenses with tax-free dollars. This will be a very valuable benefit plan to those employees with children or dependent parents. You are eligible for this plan if you incur dependent care expenses because you, or, if you are married, you and your spouse work. Eligible dependents are defined as follows: your dependent children under the age of 13; and a spouse, child or other dependent who is disabled and living with you who you claim as a dependent on your income tax and who is incapable of caring for themselves. Expenses you may claim and be reimbursed with tax-free dollars include: Wages paid to a babysitter, whether the care is provided in or outside of your home. However, the babysitter may not be someone you claim as a dependent on your tax return and must be over 18 years of age. Expenses for a babysitter can only be used for services provided during regular working hours. Babysitting for social events is not eligible for reimbursement. Services of a day care center or nursery school, providing the center complies with state and local laws. Cost for care at facilities away from home, such as family day care or adult day care centers, as long as the dependent returns home for at least eight hours of a 24-hour day. Wages paid to a care giver/home aide for providing care for an eligible dependent. Any other qualified dependent care expenses as defined by the IRS. QUESTIONS & ANSWERS 1. What is the maximum amount I can contribute to the Health Care Reimbursement Account and the Dependent Care Reimbursement Account? The 2005/2006 plan year is from December 1, 2005 thru November 30, 2006. You may allocate as much as $ 2,000 of your 2005/2006 income into your Health Care Reimbursement Account. The maximum you may allocate to the Dependent Care Reimbursement Account for the 2005/2006 plan year is $5000. 2. What should I take into consideration when deciding how much to deposit into the Health Care Reimbursement Account? Consider how much you have spent in the past year for expenses not covered by a health benefit plan. Also, consider the medical plan option in which you will enroll. If your option contains an annual deductible and coinsurance feature, direct a portion of your earning into the Reimbursement Account so you can be reimbursed for these expenses with tax-free dollars. 3. What if I join both the Health Care and Dependent Care Reimbursement Accounts and discover that I have underestimated the sum of dependent day care expenses I will incur? Can I submit day care claims and be reimbursed with funds from my Health Care Reimbursement Account? No. The Health Care and Dependent Care Accounts are two distinct accounts. Therefore, the funds in the Reimbursement Accounts must be kept separate. In other words, only eligibl e health care expenses may be reimbursed with funds you have deposited into the Health Care Reimbursement Account and only eligible dependent care expenses may be reimbursed with funds deposited into the Dependent Care Reimbursement Account. 4. What if I do not claim all the funds I have deposited into the Health Care Reimbursement Account or the Dependent Care Reimbursement Account? We encourage all employees to conservatively elect how much to deposit into the Health Care and Dependent Care Reimbursement Accounts because the IRS requires that money in the Reimbursement Accounts not used for eligible expenses incurred in that same year be forfeited. This is known as the "use it or lose it" rule. This may sound intimidating, but do not let it keep you from participating in the Reimbursement Accounts. Remember that the risk of forfeiture can be reduced significantly. Consider, for example, that many out-of-pocket health care and dependent care expenses are predictable. Dependent care expenses can be budgeted ahead of time. And don't overlook commonly incurred and unreimbursed health care expenses, such as annual plan deductibles, coinsurance features, routine physical exams, monthly prescriptions, etc. 5. Once I join Health Care or Dependent Care Reimbursement Accounts, will I be able to change how much of my income is redirected to the Reimbursement Accounts? Each year you decide if you want to participate in one or both of the Reimbursement Accounts for the following year. If so, you decide how much to contribute to each Reimbursement Account. You cannot stop, start or change this decision during the year unless a change in your family status occurs, as defined by the IRS. Family status changes are: marriage or divorce birth or adoption of a child termination of employment death of an eligible dependent 6. Because the Health Care and Dependent Care Reimbursement Accounts reduce my earnings and allow me to use tax-free dollars to pay for certain expenses, will my Social Security Benefits be affected when I retire? If your reduced earnings are less than the annual Social Security earnings maximum, your future Social Security benefits may be reduced. However, the reduction is generally minimal. 7. I currently take a credit on my income tax statement for the dependent care expenses that I incur. Which is more advantageous; the Dependent Care Tax Credit or the Dependent Care Reimbursement Account? Currently, the Dependent Care Reimbursement Account has better tax advantages for those with $25,000 or more in joint income, while the IRS tax credit is better for those with less than $25,000 in joint income. This is a general rule only. Consult your tax preparer for information on your own circumstances. 8. Can I use both the Dependent Care Reimbursement Account and the Dependent Care Tax Credit? Yes. However, your tax credit must be reduced by the amount you contributed to the Reimbursement Account. 9. How do I file for the reimbursement and how often will reimbursements be issued? To receive reimbursement of eligible expenses from your Health Care or Dependent Care Reimbursement Account, submit a claim form with an itemized bill and/or receipt directly to AdminPro, Inc. Reimbursements will be processed on the 15th of each month. Claim forms for Health Care and Dependent Care reimbursement requests are available in the Human Resource Department. Send claim forms to AdminPro, 1423 E 11 Mile Rd. Royal Oak, MI 48067-3836. If you have any questions please contact Karen Armaly at (248) 543-2644 x1002 or by fax at (248) 543-2296. 10. Is there a deadline for filing Health Care and Dependent Care Reimbursement claims? Yes. You may file claims incurred in the 2005/2006 plan year as late as February 28, 2007 11. If I deposit funds into a Health Care Reimbursement Account and then terminate my employment, will I still have access to the money I have deposited but not yet claimed? Yes. You will be able to submit and be reimbursed for claims incurred prior to your termination date. These same rules apply to the Dependent Care Reimbursement Account.
Pages to are hidden for
"FLEXIBLE SPENDING ACCOUNT CLAIM FORM"Please download to view full document