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Flexible Benefit Plan
Medical Dependent/Child Care
Reimbursement Acct. Worksheet

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In using this calculator to estimate your Dependent Care Expenses, you should estimate conservatively and use only those expenses that you can accurately predict. Any dollars that remain in your Reimbursement Account at the end of the Plan Year are forfeited by law, and you lose the money.

Listed below are some categories of Dependent Care Expenses that you may incur each year. Also, you will want to consider wheter you will have any unusual dependent care expenses during the current Plan Year.

Note: Expenses are allowable only if the dependent care is work-related. It does not cover baby-sitting expenses related to entertainment or other non-work related times.

Eligible types of day-care providers are:

• Licensed day-care center
• Licensed day-care, home based
• Private baby-sitter (in your home or theirs)
• Nursery school
• Private pre-school program
• Public or private before-school and after-school program
• Public or private summer day camps

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Expenses*:	Prior Year's	Estimated Current Year's

Infant/Toddler	$	$
Preschool	$	$
Before-school or after school	$	$
Reporting Days (Child in school only half days)	$	$
School In-Service Days (Child not in school)	$	$
School Holidays	$	$
School Vacations	$	$
Summer Day Camp	$	$

Total	$	$