Dependent Day Care Registration Statement

PLEASE read prior to completing the Dependent Care Assistance Program Registration Statement:

A qualifying dependent for the Dependent Care Assistance Plan is a dependent child UNDER THE AGE OF 13 or a spouse or other dependent adult who’s not able to care for him or herself.
Dependent care expenses must be utilized for the specific purpose of allowing both you and your spouse to work (unless disabled, physically or mentally incapable of self-care, attending school full-time or actively seeking employment).
The payments for care cannot be paid to someone you can claim as your dependent on your tax return or to a child who is under age 19.
You must be able to claim the child as an exemption on your tax return. For an exception see Section 152(e) of the Internal Revenue Code concerning dependents of divorced or separated parents or parents who live apart.
Valid expenses include child day care, nursery school, before- and after-school care, adult care and in-home dependent care.

SLEEP AWAY CAMPS ARE NOT ELIGIBLE

Tuition for Kindergarten Schooling and higher is not a valid expense.

Internal Revenue Code Section 129 limits the maximum election amount to $5,000 ($2,500 for married filing separately) OR the employee’s earned income (if less than $5,000/$2,500) OR the spouse’s earned income (if less than $5,000/$2,500)

*Please note that claims will not be paid without a Dependent Care Registration Statement on file. A new form must be completed each year. All sections MUST be completed.

** Dependent Day Care Registration Statement is not considered an ENROLLMENT form **

Attach A Completed DC Registration Statement Here OR Complete The Form Below

Employee Required Information

Employee First & Last Name *

Employer Name *

Email Address *

Last 4 SSN *

Address, City, State, Zip *

Spouse Required Information

Spouse's Name:

Spouse's Employer:

If Spouse is NOT employed:
Is Spouse incapacitated?

Yes

No

If Spouse is NOT employed:
Is Spouse a full-time student?

Yes

No

Name of University & Enrollment Status:

If your spouse is not incapacitated and is not employed, this would result in being ineligible to participate in the Dependent Care Assistance Program. It is the understanding that your spouse is capable of caring for your dependents while you are at work.

Dependent Required Information

Dependents

	Name	Relationship	Date of Birth
Dependent #1	Name	Relationship	Date of Birth
Dependent #2	Name	Relationship	Date of Birth
Dependent #3	Name	Relationship	Date of Birth

Do you have custody AND pay the day care expenses for the above-named dependent(s)?

Yes

No

If you are using dependent day care coverage under the Flexible Benefits Plan for your spouse and/or other tax dependents OVER the age of 13, is that person physically or mentally incapable of caring for him or herself?

Yes

No

In reference to the above questions, does the qualifying dependent spend at least eight (8) hours per day in the employee's household? (The qualifying dependent is required to live with you in order to be eligible for enrollment in this Pre-Tax category.)

Yes

No

Dependent Day Care Provider Information

Name of Service/Care Provider:

Plan Year You Are Filing For: *

2023

2024

Type of Care Services Provided:

Address, City, State, Zip 🛈

Tax Identification Number OR FULL Social Security Number: * 🛈

If Not A Facility/Business, What Is Care Providers Relationship To EMPLOYEE?

If services are being provided at a day care center (i.e. a facility that provides for more than six (6) individuals not residing at the center), does the day care center comply with all applicable state laws and regulations? *

Yes

No

If service is being performed by one of your children, how old is the child? (Anyone under the age of 19 is not an eligible service provider)

Yes, the age of the child is: Yes, the age of the child is:

Annual Cost of Day Care Services: $ *

I certify that the foregoing information is correct and true to the best of my knowledge. I agree to inform Flexbene immediately of any change in the foregoing information. Electronically Sign this form by writing your FULL FIRST & LAST NAME BELOW. *

Date of Signature * +