Calculate Your
Tax Savings

By completing the following information, you can calculate your annual reimbursable expenses.

Select Your Annual Income

Select Your Pay Cycle

Insurance Premiums (only if payroll deducted)
Health Insurance $
Group Term Life Insurance $
Disability coverage $
Vision and/or Dental Insurance $
Other $
Total $

Healthcare Expenses (estimated)
Doctor visits and co-pays $
Deductibles $
Prescription drugs $
Prescribed medical supplies/equipment $
Travel to doctor or hospital $
Eye exams & surgery $
Glasses/contacts/solutions $
Dental checkups $
Fillings/crowns $
Orthodontia $
Chiropractic $
Other $
Total $

Dependent Care Expenses (estimated)
Children $
Adults $
Total $

Adoption Expenses (estimated)
Attorney fees $
Court costs $
Legal adoption fees $
Other $
Total $

Estimated Annual Expenses and Tax Savings
Total Insurance Premiums $
Total Healthcare Expenses $
Total Dependent Care Expenses $
Total Adoption Expenses $
Total Annual Expenses $
Annual Tax Savings $
Estimated Savings 
Amount Per Paycheck		 $

Tax Estimate Table

The following tax rates are estimated based on a combination of social security, federal, and state income taxes (national averages) and may not reflect your actual tax rate.

If your
annual household
earnings are:

Estimated 
tax rate is:

Less than $30,000
$30,000 - $40,000
$40,000 - $70,000
Greater than $70,000

25%
29%
31%
33%
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