This worksheet is designed to help make the most of your Flexible

This worksheet is designed to help make the most of your Flexible Spending Account(s).  Estimating the amount of your eligible expenses for last year will help you determine how many pre-tax dollars the University should deduct from your paycheck for reimbursement from your Flexible Spending Account(s).

For each eligible expense listed, calculate the amount of out-of-pocket expenses you paid last year (out-of-pocket expenses are those not covered by your insurance or that of your spouse's.)  If you will have similar expenses next year or if you plan to incur other expenses, estimate that amount for your current year's estimated expenses.  (You should be conservative with your estimates because Flexible Spending Account funds that you do not use during the year will be forfeited in accordance with IRS rules.)

After adding your expected expenses, divide the total by 26 to estimate your per-pay-period deduction and round off to the nearest dollar.  This is the amount you will enter on the Flexible Spending Enrollment Form.

Health CareYear _____ ExpensesYear ______ Expenses
Deductibles and Co-payments $ $
Routine Physical Exams $ $
Physician's Office/Clinic Visits $ $
Dental Care (including co-pays, fluoride treatments, orthodontia) $ $
Vision Care (exams, glasses/contacts) $ $
Hearing Care/Hearing Aids $ $
Prescription Drugs (including co-payments) $ $
Surgical Expenses $ $
Other Hospital Expenses $ $
Emergency Room Visits $ $
Immunizations/Well Baby Care $ $
Travel to and from Physician's/Clinic $ $
X-rays/Laboratory Tests $ $
Other $ $
Health Care $ $
Health Care Deduction/Pay Period $ $

Dependent CareYear ______ ExpensesYear ______ Expenses
Wages and Salary paid to provider (including Social Security and other taxes) $ $
Child Care Center $ $
Licensed Nursery School $ $
Dependent Adult Care Expenses (usually a parent being cared for in your home) $ $
Other Qualified Expenses $ $
Dependent Care Total $ $
Dependent Care Deduction/Pay Period $ $