FSA Estimation Worksheet

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):
Coinsurance or Copayments for Medical Plan	Your Estimated Amount
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 Expences for Custodial Care	$
Coinsurance for Dental Plan
Diagnostic and Preventive Procedures	$
Restorative and Other Services	$
Orthodontia, Including Charges that Exceed the Established Maximum	$
Dental Expences that Exceed the Yearly Maximum	$
Travel-Related Expences	$
Other Eligibile Medical / Dental Expences	$
Medical and Dental Section Total (The total cannot exceed $5,000.00 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
Use the following form to estimate your dependent care for the year.
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: NOTE: Expenses claimed cannot be more than your earned income or your spouse's earned income, whichever is less.
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:	$
Estimated Annual Dependent Care Expenses: ($5,000.00 maximum if single married filing jointly; $2,500.00 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:	$
**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. Click here to view the Simplified Marginal Tax Table. . . SIMPLIFIED MARGINAL TAX TABLE Includes (Estimated) Federal & Utah State Marginal and FICA Rates Taxable Income Single (Head of Household) Married (Filing Jointly) Over But Not Over Total Allowed % Total Allowed % 0 1,500 24.95 24.95 1,500 3,000 25.95 25.95 3,000 4,500 26.85 26.85 4,500 6,000 27.85 27.85 6,000 7,500 28.65 28.65 7,500 33,150 29.65 29.65 33,150 43,050 42.65 29.65 43,050 76,200 42.65 42.65 76,200 89,150 36.45 36.45 89,150 104,050 39.45 36.45 104,050 144,400 39.45 39.45 144,400 158,550 44.45 39.45 158,550 283,150 44.45 44.45 283,150 N/A 48.05 48.05
*This estimate is based on the income you indicated and the associated Tax Credit Percent from the Dependent Care Tax Credit Table. Click here to view the Dependent Care Tax Credit Table. . . DEPENDENT CARE TAX CREDIT TABLE Total Earned Income in Dollars Tax Credit Percent 0 to 10,000 30 10,001 to 12,000 29 12,001 to 14,000 28 14,001 to 16,000 27 16,001 to 18,000 26 18,001 to 20,000 25 20,001 to 22,000 24 22,001 to 24,000 23 24,001 to 26,000 22 26,001 to 28,000 21 28,001 and up 20

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.