UNISYS

/ Flexible Spending Account – Dependent Care
Request for Benefits
Instructions / 1. A new request for benefits form must be completed each time you request benefits.
2. Complete all requested information in the sections labeled “Employee Information” and “Person(s) Receiving Care.”
3. Attach itemized dependent care services billings, or ask your dependent care service provider(s) to complete the section labeled “Service Provider(s) Statement.” An itemized bill must show:
a. name of person(s) receiving care
b. dates services were provided
c. amount paid
d. care provider's name and address
e. care provider's signature / f. care provider's Social Security number or Taxpayer Identification Number
4. Sign and date this form, then mail to:
Benefits Payment Office - FSA
C/O Aetna, Inc.
PO Box 843
Blue Bell PA 19422-0843
5. If you have questions, call tollfree:
Telephone number:1-800-223-3580
Fax number:1-610-391-4863Outside the U.S., call: (952) 594-6250
Print the Information Below.
Employee name (first, mi., last) / Employee Social Security number

Employee

/ - -

Information

/ Street address / City / State / ZIP Code
-
Name of person(s) receiving care / Date of birth
Person(s) / Month / Day / Year

Receiving Care

Service Provider(s) / Name and address of
dependent care service provider(s) / Soc. Sec. no. or
Taxpayer I.D. no. of
care service provider / Dates of care
From / Through / Amount paid / Signature of service provider
Statement
/ - -
- -
Employee
Signature / I understand that these expenses cannot be reimbursed from any other source and that amounts reimbursed to me cannot be claimed on my income tax returns. I further understand and acknowledge that total dependent care expenses reimbursed to me should not exceed the lesser of my or my spouse’s earned income and that all expenses meet applicable IRS guidelines for reimbursement, including those described below.
Sign here / Date

FederalIncome TaxGuidelines

/ For your Flexible Spending Account - Dependent Care, the definition of eligible dependents is different from the definition used by the Unisys Medical Plan and Unisys Dental Plan. You may incur eligible dependent care expenses for:
(1) a child under age 13 for whom you are entitled to a federal income tax dependency exemption,
(2) your spouse who is physically or mentally incapable of selfcare, or
(3) any other person who is physically or mentally incapable of selfcare and for whom you are entitled to a federal income tax dependency exemption or for whom you would be entitled to the exemption except for the fact that the person had income exceeding the exemption allowance.
Note: If you are divorced or legally separated, an underage13 child or mentally/physically handicapped person is still eligible as long as you have legal custody, even if you are not entitled to the federal income tax exemption.
Dependent care expenses may be reimbursed only when incurred in order for you to be employed. If you are married, your spouse must also be employed or be a fulltime student.
If expenses are incurred at a dependent care center that cares for more than six individuals, other than those who reside at the center, the center must comply with all state and local laws.
If services are provided outside your home for an individual over age 13, the individual must spend at least 8 hours per day in your home.
Services cannot be provided by someone you take as a federal income tax exemption or by your child who is under age 19.
Payments can be made, however, to a relative who is not your dependent, even if the relative lives with you.
Current federal law requires that you provide the name, address and Social Security number, or Taxpayer Identification Number, of the care provider on your federal income tax return, unless the care provider is a taxexempt 501(C) (3) organization.
This form is available as a Word template via dotcom - Forms/Ordering - Corporate Forms / 4306 0573-004 (6/03)