ROANOKECOLLEGE

FLEXIBLE SPENDING ACCOUNT REIMBURSEMENT REQUEST FORM

NAME: / SOCIAL SECURITY #
DEPT: / EXT #

COMPLETE THIS PORTION FOR HEALTHCARE RELATED EXPENSES: HR ACCT #

EXPENSES PAID TO: / DATE OF EXPENSE / SELF/DEPENDENT / AMOUNT DUE
0.00
0.00
0.00
0.00
0.00
0.00
Total / $0.00

COMPLETE THIS PORTION FOR DEPENDENT CARE EXPENSES: HR ACCT #

EXPENSES PAID TO: / SS# OR TAXPAYER ID / DATE OF EXPENSE / AMOUNT DUE
0.00
0.00
0.00
Total / $0.00

I request reimbursement from my Flexible Spending Account(s) for the expenses itemized above. I have attached a statement from the provider of services showing the amount of each expense and the date it was incurred. The expenses are not eligible for reimbursement from any other source. I certify that these expenses qualify for reimbursement under the Internal Revenue Code. I also understand that reimbursed expenses cannot be claimed as deductions on my personal tax return.

The information on this Request for Reimbursement is true and correct to the best of my knowledge.

______

Employee SignatureDate

FOR HUMAN RESOURCES USE ONLY
DATE PROCESSED: ______BY: ______
DATE DENIED: ______BY: ______

SEND CHECK: Via Campus Mail Mail to home address Will pick up

GUIDELINES FOR ELIGIBLE REIMBURSEMENTS

HEALTH CARE EXPENSES

Eligible Healthcare expenses must meet the following guidelines:

  • You, your spouse or your dependents must incur the expenses.
  • The expenses must be incurred after the effective date of your flexible spending account and during the plan year. If your employment terminates or you cease making contributions to your flexible spending account, expenses must be incurred before the date you ceased to participate in the flexible spending account plan.
  • The expenses cannot be eligible for reimbursement from any other source, including any health insurance plan.
  • Eligible expenses are any health care expenses that are considered tax deductible by the IRS. A list of IRS approved expenses is available from the Human Resources Department.
  • You cannot claim a deduction on your personal tax return for any expenses reimbursed from your spending account.

DEPENDENT CARE EXPENSES

Eligible dependent care expenses must meet the following guidelines:

  • The care must be for a child age 13 or under, a physically or mentally disabled child, spouse or dependent parent who is incapable of self-care.
  • You must be working while your dependents receive care. If you are married, your spouse must also work, be a full-time student at least five months a year or be incapable of self-care and unable to provide for his/her own care.
  • Eligible expenses include charges by (1) daycare centers, (2) nursery schools, or (3) individuals who provide care for your dependents. The individual providing care cannot be a dependent or your child under age 19.
  • The expenses must be incurred after the effective date of your flexible spending account and during the plan year. If your employment terminates or you cease making contributions to your flexible spending account, expenses must be incurred before the date you ceased to participate in the flexible spending account plan.
  • You cannot file for reimbursement of expenses that have already been reimbursed from another source.
  • You cannot claim a tax credit on your personal tax return for any dependent care costs reimbursed from your spending account. The maximum allowable combined amount of tax credit plus flexible spending account reimbursement for the calendar year is: (1) $5,000 if you are single; (2) $5,000 if you are married and file your income tax return jointly; and, (3) $2,500 if you are married and file your income tax returns separately.
  • If you are married, the amount of reimbursement is limited to the lower of the annual income of you or your spouse. If your spouse is a student or incapable of self-care, it is assumed that your spouse earns $200 per month if care is provided for one dependent, or $400 per month if care is provided for 2 or more dependents. Your spouse’s annual income is based on the actual number of months during which he/she is a student or incapable of self-care during the year.