Estimate your health and dependent care expenses for the Plan Year. Include all expenses except insurance premiums for you, your spouse and all dependents claimed for taxes.
A. HEALTH CARE EXPENSES (Click here for guidelines)
MEDICAL
1. Deductibles / Co-Pays / Co-Insurance	$
2. Prescription Drugs	$
3. Mental Health Services	$
DENTAL
1. Deductibles / Co-Insurance	$
2. Orthodontia	$
VISION
1. Exams / Eye Glasses	$
2. Contacts / Contact Cleaning Solutions	$
OTHER HEALTH EXPENSES
1. Chiropractic	$
2. Hearing Aids	$
3. Other - refer to health care list for eligible expenses	$
B. DEPENDENT CARE EXPENSES
[Up to $5,000 per household, per calendar year, for the care of disabled adults of any age and children to age 13; married filing seperately limit is $2,500]	$
C. ANNUAL INCOME Include Spouse if Joint Filer	Less Than $21,525 $21,526-$25,750 $25,751-$34,550 $34,551-$43,050 $43,051-$52,025 $52,026-$62,450 $62,451-$72,600 $72,601-$79,275 $79,276-$89,150 $89,151-$104,050 $104,051-$130,250 $130,251-$141,575 $141,576-$144,400 $144,401-$158,550 $158,551-$283,150 Greater Than $283,150
D. TAX FILING STATUS	Single Married Filing Joint Married Filing Single Head of Household
TAX-FREE INCOME WITH FLEX-PLAN
Total Expenses
Monthly Savings
Annual Savings
Note: Your tax savings is based on marginal federal rates and FICA. For extra tax savings, multiply State income tax rates of 3% to 9% by the Total Expenses noted above.