EBS - Flexible Spending

Estimated Annual Income:

Dental:

Subtotal:

Vision care expenses, such as:

Subtotal:

Medical Expenses:

Subtotal:

	-Prescription Drugs	$
	-Over-the-counter drugs (see list)	$
	-Medical Deductibles and CoInsurance	$
	-HMO copayments	$
	-Routine physical exams	$
	-Other eligible expenses (examples)	$

Total Estimated Health Care Expenses:

Dependent Care FSA ($5000.00 max)

Subtotal:

	-Day Care Center	$
	-Baby Sitter	$
	-Nursery School	$
	-Summer Day Camp	$
	-Payment to a dependent care facility or individual	$
	-Payment to other adult care providers	$
	-Other	$

Total Estimated Dependent Care Expenses:

This calculator estimates 15% Federal Tax Rate, 7.65% FICA, and 4% State Tax Rate. Your actual savings may vary depending on your own circumstances.