Pre-Tax Expense Accounts Worksheet

Use this worksheet to help guide your funding calculations. See your Summary Plan Description for additional information.

Section 1: Funding Your Health Care Account

Write in the amounts you think you'll pay out-of-pocket for you and your family members during the plan year (July 1 - June 30) for the expenses listed below.

Medical plan deductibles	$ ____________
Medical plan coinsurance (the amount you pay after you satisfy the deductible)	$ ____________
Medical Plan or HMO co-payments (the amount you pay at the time the service is provided)	$ ____________
Dental plan deductibles and coinsurance amounts	$ ____________
Uninsured medical and dental expenses (e.g., orthodontia for adults, dependent dental expenses if you have less than three years of service)	$ ____________
Medical and dental expenses above R&C or UCR limits	$ ____________
Total estimated out-of-pocket health care expenses	$ ____________
HEALTH CARE ACCOUNT CONTRIBUTION	$ ____________

Section 2: Funding Your Dependent Care Account

To estimate your dependent care expenses for the plan year (July 1 - June 30), write in your estimated weekly expense and multiply it by the number of weeks of dependent care expenses you will incur.

$____________	X	______________	=	$_____________
Weekly Expense		Number of Weeks		Annual Total

Dependent Care Account Contribution

*Your contribution cannot exceed the lesser of your or your spouse's taxable income. Subject to IRS limits, your annual contribution per family generally cannot exceed $5,000 during both the calendar year (January 1 - December 31) and plan year (July 1 - June 30).