Office of Labor Relations

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	HEALTH CARE FLEXIBLE SPENDING ACCOUNT (HCFSA) PROGRAM SAVINGS CALCULATOR - Enter the requested information below to calculate your HCFSA Tax Savings - Use the TAB key or mouse to move within the worksheet - Do not use the ENTER key as a way to navigate through this worksheet or to complete your calculation.
	Number of Exemptions Claimed: Federal State City
	Tax Status: Single Married
	Your Gross Annual Income: $
	Are you in the Pension System? Yes No Annual Pension Contribution: $
	Enter annual Health Insurance Premium: $
	Enter annual contribution to the Health Care Flexible Spending Account Program (maximum $5,000, including $48 annual administrative fee): $
	If you participate in the Dependent Care Assistance Program enter annual contribution (maximum $5,000, including $48 annual administrative fee): $
	Enter annual contribution to the TDA Plans (457, 401k, 403b), including Deferral Acceleration for Retirement (DAR), if any: $ Excluding DAR, is your annual contribution to any one of the TDA Plans equal to or more than 7.5% of your gross annual income? Yes No
	Enter annual After-Tax Deductions (MCU, Union Dues, Saving Bonds, Pension Loan, Child Support, etc.): $

HCFSA SAVINGS
		With HCFSA	Without HCFSA
YOUR GROSS ANNUAL INCOME:		$	$
P R E T A X	Pension Contribution:
	Health Insurance Premium:
	Annual amount for Health Care Flexible Spending Account Program Expenses:
	Health Care Flexible Spending Account Program Administrative Fee:
	Dependent Care Assistance Program annual contribution:
	Deferred Compensation Plan annual contribution:
ADJUSTED GROSS INCOME:		$	$
Federal Income Tax:
New York State Income Tax
New York City Income Tax
FICA Deductions
Medicare Deductions
After-Tax Cost of Health Care Expenses
After-Tax Deductions (MCU, Union Dues, Saving Bonds, Pension Loan, Child Support, etc.)
TAKE-HOME PAY
HCFSA TAX SAVINGS
Please Note: 1) This worksheet provides only estimates of tax information and should not be assumed to be tax advice. Be sure to consult a tax advisor to determine the appropriate tax advice for your financial situation. 2) This worksheet is not intended nor shall be construed as a guarantee of tax savings.
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