Page 60 - Touching All the Bases

0 4 Estimate your F S A Expenses and Tax Savings

M E D I C A L E S T I M A T E
Estimate out-of-pocket medical services for you, your spouse, and your eligible dependents.

G E N E R A L E X P E N S E S S P E C I A L T Y E X P E N S E S
Office visits/doctor’s fees Emergency room/hospital bills $
(actual cost if deductible applies $
or total copayments)
Hearing aids $
Immunizations/vaccines $
Specialists or alternative medicine
Laboratory fees/X-rays $ (Acupuncture, chiropractor, physical $
therapy, specialists fees, etc.)
Over-the-counter drugs and medicines $ Surgery $
Prescription drugs $ Other expenses $

S U B T O T A L $ S U B T O T A L $
V I S I O N D E N T A L
Cleanings, exams, fillings,
Corrective eye $
surgery and eye wear $ and procedures
Orthodontia $
Eye exams $
X-rays $
Prescription glasses $
S U B T O T A L $
Contact lenses $
S U B T O T A L $ T O T A L E S T I M A T E : $

D E P E N D E N T C A R E E S T I M A T E T A X S A V I N G S E S T I M A T E
Estimate out-of-pocket expenses related to non- Estimate your total annual tax savings.
medical care for your dependents.

A. Total medical estimate (see plan
$
highlights for the maximum limits that may apply)
D E P E N D E N T C A R E E X P E N S E S
B. Total dependent care estimate (see plan
Adult day care $ $
highlights for the maximum limits that may apply)
Child day care or in-
$
home dependent care C. Total expenses (line A + line B) $
Nursery school $
D. Tax rate (enter what you pay in total for
Federal, State, and Local taxes. If uncertain, $
use 30% of your gross salary)
T O T A L E S T I M A T E : $
E. FICA (includes Social Security and Medicare) $
F. Total tax rate (line D + line E) $
Use our free FSA calculator to help estimate your
E S T I M A T E D A N N U A L
expenses: BenefitResource.com/estimate. T A X S A V I N G S (line C x line F) $