HomeMy WebLinkAboutFlex dependent care reimbursement41 ThrivePass
Dependent Care Claim Form
PLEASE PRINT -see reverse side for claim submission options and instructions
Name __________________ _ SSN or Emp ID I
Address ________________ _ Daytime Phone# ______________ _
Employer Name ______________ _
D Please check box for change of address. Please also notify your Human Resources Department of the change
EXPENSES
Dates of service Amount of Name and relationship of child or other dependent for
From -To Expense whom services were provided
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PARTICIPANT CERTIFICATION
I request payment from my Dependent Care account for the above expenses. To the best of my knowledge, these expenses are
eligible under the plan (see reverse side). I certify that they have not been reimbursed and that I will not seek reimbursement from
another source. I further certify that my spouse (if married): is employed, actively seeking employment, is a full-time student for at
least five months of the year, or is incapable of caring for himself or herself. I understand that these expenses may not be claimed
as an income tax deduction or for an income tax credit.
Signature ____________________ _ Date _____________ _
PROVIDER'S VERIFICATION OF DEPENDENT CARE EXPENSES
(To be completed by provider in place of a formal billing or receipt. Please print.)
Provider Name ________________ Tax I.D. #or SS# __________ _
Provider Address _______________________________ _
I certify the dates of service and amount of expenses for dependent care described above.
Provider Signature _____________________ Date _________ _
ThrivePass, P.O. Box 220, Minneapolis, MN 55440-0220
Customer Service: 866-855-2844
Claims Fax: 888-265-5413
app.thrivepass.com
VISIT APP.THRIVEPASS.COM TO FILE CLAIMS ELECTRONICALLY
•Enter your username and password
•Click on the "Pre-Tax" tile from your home page
•Click "File a Claim" from the "Manage Account" section
•Follow the instructions and enter claim information
•Upload your supporting documentation -see back of form for documentation requirements
•You can also sign up for E-mail I Text Notifications & Direct Deposit
TRY OUR MOBILE APP -THRIVEPASS -AND FILE CLAIMS FROM THE PALM OF YOUR HAND
•Download the app from the Google PlayStore or iOS app-store
•Set up your four-digit PIN, and away you go
•Upload your documentation, complete a few fields, and click "submit" -it's as easy as that!
INSTRUCTIONS/ TIPS FOR MANUAL CLAIM SUBMISSION:
Form must be fully completed, including signature and date -incomplete forms may delay processing
Use the Verification of Dependent Care Expenses on the front page of this form OR attach supporting documentation.
Documentation must show the nature and amount of expense plus date incurred. Unacceptable documentation includes
cancelled checks, balance forward or balance due receipts, and payment on account receipts that do not include date range of
rendered services.
Please keep copies of your submissions -Documentation will not be returned
Mailed claims may have slower turnaround time.
Mailed claims may be scanned and stored electronically. Original claim form & documentation will be destroyed.
E-mail Notification service -see our website for details on how to receive electronic notification when your claim has been
received and/or processed. Please allow two business days for notification.
ELIGIBLE EXPENSES
Dependent care expenses that allow you (and your spouse if you are married) to be gainfully employed are eligible.
Note that if you (or your spouse if you are married) are not employed, you must either be actively seeking employment, be a
full-time student, or incapable of self-care in order to claim dependent care expenses.
Care that is primarily for medical or educational (i.e., kindergarten) purposes is not eligible.
Meals, snacks, field-trips / special activity fees are not eligible unless inseparable from and incidental to the cost of care.
Overnight camps are not eligible, even if the overnight portion is split out separately from the day portion.
ELIGIBLE DEPENDENTS
Your children or other qualifying relatives under age 13 who you may claim as a dependent
Your spouse or other dependent who is incapable of self-care who lives with you for more than one-half of the year and, in the
case of a dependent, whose gross income for the year does not exceed the exemption amount.
CARE PROVIDERS
If care is provided outside the home in a "dependent care center," the center must comply with all applicable laws and
regulations of the state (or unit of local government) in which located. A "dependent care center" is a facility that provides care
for more than six nonresident people, and receives a fee, payment, or grant for providing such services.
Care can also be provided outside the home if the provider cares for less than seven nonresident individuals. In this situation,
compliance with applicable laws and regulations of the state (or unit of local government) is not required.
The employee's dependents and children of the employee under age 19 are not eligible dependent care providers.
The maximum reimbursement from this plan and any other dependent care plan for which you may be eligible is $5,000 per year
($2,500 if you are married filing separately). Reimbursement is further limited to the "earned" income of the lower earning spouse. In
general, earned income means income from employment such as wages, salaries and tips. If your spouse is a full-time student or
incapable of caring for himself or herself, you may assume an earned income of $250 per month for one qualifying dependent or $500
per month for two or more qualifying dependents.
Contributions can be used only for reimbursement of expenses incurred during the plan year starting on your participation date.
Expenses are incurred on the date services are provided. Any balance in your account after the claim submission cut-off date for a plan
year will be forfeited. Dependent care expenses reimbursed through the plan cannot be applied toward the dependent care tax credit.
Maximum expenses for the tax credit calculation are reduced, dollar for dollar, by the amount of expenses reimbursed through this plan.
Note: The rules described above are a general summary of the actual requirements. Refer to your Summary Plan Description
for more detailed information.
ThrivePass, P.O. Box 220, Minneapolis, MN 55440-0220
Customer Service: 866-855-2844
Claims Fax: 888-265-5413
app.thrivepass.com