Dependent Care FSA Claim Form
Reimbursement claim for a Dependent Care FSA (DCFSA) — covers daycare, after-school, summer camp.
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DEPENDENT CARE FSA — REIMBURSEMENT CLAIM
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EMPLOYEE
Name: Jordan Alex Taylor
Employee ID: EMP-1138
Employer: Acme Corporation
FSA administrator: HealthEquity (planhealth.com)
Plan year: 2026
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DEPENDENT
Name: Ellis Taylor
Date of birth: September 4, 2018
Relationship: Child under age 13
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CARE PROVIDER
Name: Sunshine Day School
Address: 120 Belmont Street, Portland, OR 97214
Tax ID (EIN or SSN): 93-1284402
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SERVICE DETAILS
Service period: April 1, 2026 to April 30, 2026
Service type: Full-time daycare
Amount claimed: $1,450.00
Payment method: ACH
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CERTIFICATION
I certify under penalty of perjury that:
(a) The dependent listed above is my qualifying dependent under IRC §152 and §21, who lives with me for more than half the year and who is either (i) a child under age 13, or (ii) a spouse or other dependent physically or mentally incapable of self-care.
(b) The care described above was incurred to enable me (and my spouse, if married) to be gainfully employed (work, actively look for work, or attend school full-time).
(c) The care expenses claimed have not been and will not be reimbursed from any other source.
(d) The provider information above is accurate; I will report the provider on Form 2441 with my federal tax return.
(e) The amounts claimed will not be claimed again as a Dependent Care Tax Credit under IRC §21 (no double-dipping).
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REQUIRED ATTACHMENTS
□ Itemised receipt or invoice from the care provider, showing:
• Provider name and address
• Service dates
• Dollar amount paid
• Type of service
□ Signed by the provider OR provider's W-9 / EIN proof on file
□ For summer camp: confirmation that camp is DAY camp, not overnight (overnight camps are NOT DCFSA-eligible)
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EMPLOYEE SIGNATURE
_______________________________ Date: ____________________
Jordan Alex Taylor
About this template
A Dependent Care Flexible Spending Account (DCFSA) is one of the most under-used pre-tax benefits available to working parents. The annual limit is $5,000 for single filers and married-filing-jointly ($2,500 if married-filing-separately) per IRC §129; this is set by statute and unchanged for many years. Contributions come out pre-tax, reducing federal income tax, FICA, and most state taxes — for a household in the 22% federal bracket, that is roughly $1,500 in tax savings on the full $5,000. The DCFSA covers daycare, before- and after-school programs, day camp, and in-home care for children under 13, plus elder care for a spouse or dependent incapable of self-care. Overnight camps and tuition for kindergarten or above do NOT qualify (kindergarten is considered education, not dependent care, regardless of the child's age). Reimbursement claims require an itemised receipt or invoice from the provider showing service dates, amount, and provider tax ID — this is the same documentation needed to claim the Dependent Care Tax Credit (DCTC) on Form 2441, but you cannot use the same dollar of expense for both — DCFSA reimbursement reduces the DCTC base. For most families, DCFSA is the better choice up to the $5,000 limit, with any expense above that potentially eligible for the partially-refundable DCTC. The "use-it-or-lose-it" rule applies; some plans offer a $570 carryover (2025-indexed) or a 2.5-month grace period, but not both — check your plan documents.
When to use it
- Submitting reimbursement for daycare or after-school care.
- Claiming summer day camp expenses (kids stay overnight at home).
- Reimbursing for an in-home nanny or au pair.
- Adult day care for a dependent or spouse incapable of self-care.
- Year-end claim before plan use-it-or-lose-it deadline.
What to include
- Employee, employer, and FSA administrator info.
- Dependent name, DOB, and qualifying relationship.
- Care provider name, address, and Tax ID.
- Service dates, type, and amount.
- Itemised receipt or invoice attachment.
- Employee certification under §129.