FlexOptions Tax Savings & Contribution Worksheet
This worksheet will help you estimate your annual uninsured health care, and dependent care, if applicable, for
the upcoming plan year, and your estimated tax savings realized through participation in pretax plans. If you are
participating in the Health FSA and DCAP plans, remember to estimate conservatively, considering only those
eligible expenses* you are confident will be incurred during the plan year, and that will not be covered by any
insurance plan.
Projected Plan Year
Eligible Expenses
(not covered by insurance)
1. Medical and dental expenses – HSA & Health FSA
$
$
$
$
$
$
$
$
$
$
$
$
Deductibles
Medical insurance co-payments and coinsurance
Dental insurance co-payments and coinsurance
Immunizations, injections and vaccinations
Routine examinations
Dental and orthodontic expenses
Prescription drugs or co-payments
Eye examinations, glasses and contacts
Hearing examinations
Transportation to and from medical provider
Medically necessary elective surgery
Other eligible expenses:
Sub Total for Medical Expenses
Enter the contribution amount on your CP enrollment form.
$
2. Dependent Care expenses – up to $5,000 per household, per calendar year, for the
care of disabled adults or any age and children to age 13; married filing separately limit is $2,500
Day Care, Au Pair, In-Home Care Expenses, Pre-school,
After School Care, Summer Day Camp, Adult Day Care Services, etc
Enter the contribution amount on your CP enrollment form.
$
Sub Total for Dependent Care Expenses
4. Total estimated, uninsured eligible expenses for the plan year
$
$
5. Estimated Tax Savings
a. Write down your desired annual plan year contribution.
$
b. Enter your total percentage tax bracket rate (the sum of Federal
income taxes, plus FICA tax rates).**
c. Multiply your tax bracket rate by your annual contribution to estimate
$
your annual tax savings
%
*Refer to the list of health care expenses considered eligible and ineligible by the IRS. If you have any doubt as to
whether an expense is eligible, refer to the Health Care Expense Table at www.copower.com/Pretax (call your
Flexible Benefit representative at 888-920-2322 for the access code). For Dependent Care Expenses, refer to IRS
Publication 503 Child and Dependent Care Expenses.
**Individuals will not receive CA state tax benefits for HSA contributions.
10.19.2009
Instructions for Filling out FlexOptions Tax Savings & Contribution Worksheet:
1. Enter in estimated vision and dental expenses in the appropriate highlighted rows of Section 1.
2. Enter Subtotal to come up with total estimated vision and dental expenses.
3. Enter in estimated dependent care expenses in the appropriate row of Section 2.
4. Enter Subtotal to come up with total estimated dependent care expenses.
5. Total estimated eligible expenses, Section 4, enter total from the sub total figures.
6. Section 5a, write down your desired annual plan contributions for your chosen plan(s).
7. Section 5b, add up the applicable rates from the two tax rate tables, and enter number.
(For LHFSA, DCAP plans your pre-tax elections are exempt from Social Security, Medicare, Federal,
and CA income taxes.
Do not include CA tax in the figure for 5b.)
8. Section 5c, Please calculate your estimated annual tax savings from the #'s in 5a and 5b.
General FICA Tax Rates
*Actual tax and savings may vary. Contact your tax advisor or local
IRS office for specific tax information.
Tax
Tax Rate
Maximum Wage
Base
Social Security
6.20%
$106,800
Medicare
1.45%
No limit
General Federal Personal Income Tax Rates
*Actual tax brackets and savings may vary. Contact your tax advisor or local IRS office for
specific tax information.
Tax rate
Single filers
Married filing
jointly or
qualifying
widow/widower
Married filing
separately
Head of household
Up to $8,350
Up to $16,700
Up to $8,350
Up to $11,950
$8,351 $33,950
$$16,701 $67,900
$8,351 –
$33,950
$11,951 $45,500
$33,951 $82,250
$67,901 $137,050
$33,951 –
$68,525
$45,501 $117,450
$82,251 $171,550
$137,051 $208,850
$68,526 –
$104,425
$117,451$190,200
$171,551$372,950
$208,851 $372,950
$104,426 –
$186,475
$190,201 $372,950
$372,951
or more
$372,951
or more
$186,476
or more
$372,951
or more
10%
15%
25%
28%
33%
35%
10.19.2009