Tools

FSA Calculator

A. Healthcare Expenses
Medical
1. Deductibles / Co-Pays / Co-Insurance	$
2. Prescription Drugs	$
3. Mental Health Services	$
Dental
1. Deductibles / Co-Insurance	$
2. Orthodontia	$
Vision
1. Exams / Eye Glasses	$
2. Contacts / Contact Cleaning Solutions	$
Other Health Expenses
1. Chiropractic	$
2. Hearing Aids	$
3. Other (Refer to health care list for eligible expenses)	$
B. Dependent Care Expenses
Care of disabled adults of any age and children to age 13 (Up to $5,000 per household, per calendar year; married filing separately limit is $2,500)	$
C. Income
Annual Income (Include Spouse if Joint Filer)	Select an Income Less Than $21,525 $21,526-$25,750 $25,751-$34,550 $34,551-$43,050 $43,051-$52,025 $52,026-$62,450 $62,451-$72,600 $72,601-$79,275 $79,276-$89,150 $89,151-$104,050 $104,051-$130,250 $130,251-$141,575 $141,576-$144,400 $144,401-$158,550 $158,551-$283,150 Greater Than $283,150
D. Taxes
Tax Filing Status	Select a Status Single Married Filing Joint Married Filing Single Head of Household
E. Totals
Total Expenses	$
Tax-free Income
Monthly Savings	$
Annual Savings	$

Note: Your tax savings is based on marginal federal rates and FICA. For extra tax savings,
multiply state income tax rates of 3% to 9% by the Total Expenses noted above.