This online worksheet can help you estimate how much you could contribute to your FSA. Your browser needs to allow javascript functionality for this online worksheet to work.

Three sections are included:

• Medical and Dental
• Dependent Care
• FSA Worksheet Grand Total

The Medical and Dental section helps you itemize eligible expenses and calculate a total allowable amount. The dependent care section helps you determine whether FSA or the dependent care credit allowable on your individual income tax return will provide the most savings. It also helps estimate how much salary you would like to have withheld from your income (before taxes) and allocated to the FSA program for dependent care expenses. The FSA Grand Total section summarizes the amounts you could contribute to FSA.

FSA guidelines are available for your review.

Medical and Dental Section
Examples of eligible expenses you might pay through FSA that are not generally (or fully) covered by your medical or dental plan (plans may vary):
	Your Estimated Amount
COINSURANCE OR COPAYMENTS FOR MEDICAL PLAN
Physician's Services / Office Visits	$
Mental Health Care	$
Physical or Speech Therapy	$
Chiropractic Care	$
Drug or Alcohol Abuse Treatment	$
Emergency Room	$
Inpatient Hospitalization	$
Prescription Drugs	$
VISION SERVICES (INCLUDING GLASSES & CONTACT LENSES)	$
HEARING AIDS / IMPLANTS	$
MEDICAL EXPENSES FOR CUSTODIAL CARE	$
COINSURANCE FOR DENTAL PLAN
Diagnostic and Preventive Procedures	$
Restorative and Other Services	$
Orthodontia, Including Charges that Exceed the Established Maximum	$
DENTAL EXPENSES THAT EXCEED THE YEARLY MAXIMUM	$
TRAVEL-RELATED EXPENSES	$
OTHER ELIGIBLE MEDICAL / DENTAL EXPENSES	$
MEDICAL AND DENTAL SECTION TOTAL (The total cannot exceed $5,000 according to IRS Regulations.)	$
If you aren’t going to estimate dependent care expenses, the Medical and Dental Section Total above is your estimated FSA election amount.

Dependent Care Section
				Your Estimated Amounts
A.	Estimate your total annual earned income:
	I am a single head of household I am married and file my taxes jointly I am married and file my taxes separately
	How many dependents will you claim on your tax return?
		One     Two or more
	My Estimated Annual Earned Income Before Taxes:
	My Spouse's Estimated Annual Earned Income Before Taxes (if appropriate):
	Estimate of all income:
	Estimate your exemptions and deductions
B.	Estimate your annual dependent care expenses:
	Payments made for services provided in your home for dependent child or adult care:
	Payments for child care services outside your home:
	Payments made for services outside your home for a dependent who regularly spends at least 8 hours a day in your home:
	NOTE: Expenses claimed cannot be more than your earned income or your spouse's earned income, whichever is less.
	Estimated Annual Dependent Care Expenses: ($5,000 maximum if single married filing jointly; $2,500 maximum if married filing separately)
C.	Your estimated* income tax savings for claiming dependent care expenses on your individual income tax return:
D.	Your estimated** income tax savings through the FSA program:

FSA Worksheet Grand Totals
Medical and Dental Total:
Dependent Care Total:
Grand Total:

 

Please note: You may be able to use a combination of FSA and the dependent care credit on your federal income tax return. Also, the EARNED INCOME CREDIT limit may change annually. You may also be able to increase your earned income credit.

Contact your tax consultant for more information.

TO MAKE SURE THE OPTION YOU CHOOSE (EITHER FSA OR DEPENDENT CARE CREDIT) IS RIGHT FOR YOU, CONSULT YOUR TAX ADVISOR.

**This estimate is based on the income you indicated; whether you file your taxes as a single head of household, married filing jointly, or married filing separately; and the associated percent of total from the Simplified Marginal Tax Table.

*This estimate is based on the income you indicated and the associated Tax Credit Percent from the Dependent Care Tax Credit Table.

 

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