| Salary and Tax Information |
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| Select your marital status: |
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Note: Your actual number of pay dates may be different depending on your agency's payroll cycle and when you enter the program. |
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Health Care Flexible Spending Account (HCFSA)
Note: Eligible expenses include those for you, your spouse and your dependents. |
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$ |
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$ |
Enter the amount you expect to pay during the Plan Year for the following:
Note: Only expenses not covered by FEHB, other insurance, or any other source are eligible for reimbursement with an FSA.
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$ |
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$ |
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$ |
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$ |
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$ |
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$ |
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$ |
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$ |
(Non-participating or non-network providers, visit or dollar maximums on services) |
$ |
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$ |
Dependent Care Flexible Spending Account (DCFSA)
Note: DCFSA is intended for child care and certain elder care services, and does not cover any medical or health care costs for your dependents. See HCFSA above for budgeting for these expenses. |
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$ |
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$ |
| Enter the following: |
(day care center, in-home care, after-school care) |
$ |
(day care center, in-home care) |
$ |
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$ |
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To Calculate Your Estimated FSA Account Balances and Potential Tax Savings Based Upon the Expenses You Entered, Click Here
To Clear Values Click Here
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