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Home My WebLink AboutFinal Agenda PacketCITY OF RENTON FIREMEN'S PENSION BOARD Regular Meeting 7th Floor -Mayor's Conference Room Thursday, February 18, 2010 2:00 P.M. CALL TO ORDER 2. APPROVAL OF MINUTES OF JANUARY 21, 2009 3. CORRESPONDENCE 4. MONTHLY STATEMENT TO DECEMBER 31, 2009, (Final) & MONTHLY STATEMENT TO JANUARY 31, 2010 MONTHLY BILLS AND PENSION PAYMENTS 6. UNFINISHED BUSINESS 7. NEW BUSINESS 8. ADJOURNMENT � MINUTES � FIREMEN'S PENSION BOARD CITY OF RENTON January 21, 2010 Denis Law, Mayor King Parker, Council Finance Committee Chair Bonnie Walton, City Clerk Ray Barilleaux, Fire Department Representative Bruce Phillips, Fire Department Representative Chuck Christensen, Fire Department Alternate The regular meeting of the Firemen's Pension Board was called to order by Mayor Denis Law at 2:00 p.m. in the Mayor's Conference room, 7th floor of Renton City Hall. In attendance were Board members Denis Law, King Parker, Ray Barilleaux, and Bonnie Walton. Also in attendance was Finance Department Representative Jill Masunaga. MINUTES APPROVAL MOVED BY BARILLEAUX, SECONDED BY WALTON, THE PENSION BOARD APPROVE THE MINUTES OF THE DECEMBER 17, 2009 MEETING. CARRIED. MONTHLY STATEMENT A draft financial report as of December 31, 2009, was reviewed. Total cash/investment balance was $4,329,966.63. Ms. Masunaga stated that the final December financial report will be available at the next Board meeting. MONTHLY BILLS AND PENSION PAYMENTS MOVED BY BARILLAUX, SECONDED BY PARKER, TO APPROVE THE PENSION/MEDICAL PAYMENTS FOR JANUARY 2010, IN THE TOTAL AMOUNT OF$36,110.37 TO BE PAID FROM THE FIREMEN'S PENSION FUND. CARRIED. Ms. Masunaga noted that pension payments are normally recalculated in January in accordance with union contract salary changes, but because the union contracts have expired and are not yet renegotiated,the pension payments would stay the same as 2009 for now. The Board agreed that a letter should be sent to the members with the January payments to explain that adjustments normally occurring in January will instead occur later on, after contracts have been finalized. NEW BUSINESS King Parker, 2010 Council Finance Committee Chair, was welcomed to the Firemen's Pension Board. ADJOURNMENT MOVED BY PARKER, SECONDED BY BARILLEAUX,THE MEETING OF THE FIREMEN'S PENSION BOARD BE ADJOURNED. CARRIED. Time: 2:04 p.m. ��u,�� (.C/G?��r� Bonnie Walton Firemen's Pension Board Secretary �✓ `�rr�` CITY OF RENTON - FIREMEN'S PENSION FUND � CASH & INVESTMENT ACTIVITY REPORT ��,/fI AS OF DECEMBER 31, 2009 0� Fireman's Pension Fund Comparison of Cash and Investment Activitv s ■2009 ■2008 5 � 04 0 w 0 0 3 � 2 1 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec ACTIVi'FY: ME}N"'!'hi 'Y'1'D Bi,tOCi�T ' GURR t+t� ,4GTttAL �L}J BURGET BEGINNING CASH/INV BALANCE $4,375,599.98 $4,265,991.35 $3,895,540 $4,307,865.55 $4,694,232.48 $4,203,347 RECEIPTS: Fire Insurance Premium Tax 0.00 106,622.90 90,000 0.00 85,949.42 75,000 Investment Interest 2,850.85 440,117.13 200,000 1,031.91 17,965.67 200,000 DISBURSEMENTS: Fire Pension 35,571.71 443,617.54 500,000 40,549.89 512,262.83 552,400 Fire Pension Medical 952.40 12,835.48 20,000 1,527.22 9,572.61 20,000 Office/Operating Supplies 126.24 459.88 475 0.00 372.78 459 Actuarial/Firemen's Pens 8,000.00 11,200.00 10,000 0.00 0.00 0 Reimb General/Clerical&Acct 983.00 11,801.00 11,801 829.00 9,948.00 9,948 ENDiNG CASH/tNV BALANCE $4,332;817.4$ $4,�32.$9T.4$" $3,643,2�4 �4,265,991.35 �4,265�991.35 53,895�54Q CUf2REMT PREVt�34JS'' LRST YEAR LA5T YEAR a4CTIVITY: MO{�FTM MQTVTH CURR MO F'FiEV MO CASH/State Investment Pool $1,461,538.58 $1,506,388.10 $727,571.09 $546,745.98 INVESTMENTS: CD's&State Investment Pool 0.00 0.00 454,767.46 454,767.46 Federal National Mortgage Assn 99,555.84 99,555.84 99,555.84 99,555.84 Treasury Strips 8�Zero Coupon Bonds 2,767,916.83 2,767,916.83 2,984,096.96 3,206,796.27 Interest Receivable 3,806.23 1,739.21 0.00 0.00 Interest Accrued 0.00 0.00 0.00 0.00 TOTAI.CASN ANR'INVES'�ME �' �4,332,817'.48 $4.375,5�.88 ;�4;28��991.35 �4.347,$65.55 The State Investment Pool interest 03347% 0.3327% 1.8183°/a 2.1903% H:IFINANCEIFINPLANIFIREPENI1_Fire_Pension 2010.x1s\Dec09 final Page 1 02/12/2010 ",�,' �, CITY OF RENTON - FIREMEN'S PENSION FUND CASH 8� INVESTMENT ACTIVITY REPORT AS OF JANUARY 31, 2010 Fireman's Pension Fund Comparison of Cash and Investment Activifv g ____ .__�__�.,�.. _ ._.�______.�____.�_..v.__. __.._.� _ ❑2010 ■2009 5 � � 4 0 c w 0 03 � 2 1 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec CkJF�t�NT `' 2014 2{}10 RAST YEAR 2t�9 2'OQ9 ACTIVITY: Mf}t�lthl YTD Bt1DGE1' CURR MO ACTUAL RDJ BUDGET BEGINNING CASH/INV BALANCE $4,332,817.48 $4,332,817.48 $3,895,540 $4,265,991.35 $4,265,991.35 $3,895,540 RECEIPTS: Fire Insurance Premium Tax 0.00 0.00 100,000 0.00 106,622.90 90,000 Investment Interest 1,436.17 1,436.17 200,000 207,076.37 437,266.28 200,000 DISBURSEMENTS: Fire Pension 35,071.71 35,071.71 525,000 41,526.62 443,617.54 500,000 Fire Pension Medical 1,038.66 1,038.66 25,000 75.15 12,835.48 20,000 Office/Operating Supplies 0.00 0.00 475 0.00 459.88 475 Actuarial/Firemen's Pens 0.00 0.00 0 0.00 11,200.00 10,000 Reimb General/Clerical&Acct 0.00 0.00 0 988.00 11,801.00 11,801 ENDING CASMIINV BAtANCE " $4,29$,143.28 $4,298,143.28 $3,645,d65 $4;43�,477.95 $4,329,966.63 $3,643,264 CURRENT PF2EVIOUS LAST YEAR LAST YEAR RCttViTY' MONTH MON7H GURR Md PREV MO CASH/State Investment Pool $1,425,428.21 $1,506,388.10 $892,057.69 $727,571.09 INVESTMENTS: CD's&State Investment Pool 0.00 0.00 454,767.46 454,767.46 Federal National Mortgage Assn 99,555.84 99,555.84 99,555.84 99,555.84 Treasury Strips&Zero Coupon Bonds 2,767,916.83 2,767,916.83 2,984,096.96 2,984,096.96 Interest Receivable 5,242.40 1,739.21 0.00 0.00 Interest Accrued 0.00 0.00 0.00 0.00 707AL GASFf AND lIVVESTMENTS $4,298,143.28 $4,375,599.98 $4,43Q.477.95 �4,265,991.35 The State Investment Pool interest 0.2864% 0.3327% 1.8183% 1.8183°/a H:\FINANCE\FINPLAN\FIREPEN\1_Fire_Pension_2010.xis\Jan10 Page 1 02/12/2010 � � FIREMEN'S PENSION BOARD PENSION/MEDICAL PAYMENTS FOR FEBRUARY,2010 '` . Recipient FensionAmt Medical Total�-: ' ANKENY,Charlie(Captain) $135.71 135.71 * ASHURST,James(Assistant Chief) $5,320.50 - 5,320.50 BARILLEAUX,Ray(Battalion Chief) - - BEATTEAY,Karlen(Widow) $231.70 231.70 BERGMAN,Claudette(Widow) $154.09 154.09 CHRISTENSON,Chuck(Firefighter) $259.09 259.09 GEISSLER,Dick(Fire Chiefl - - GOODWIN,Charles(Captain) $4,231.00 731.70 4,962.70 GOODWIN,Donald(Firefighter) $1,018.60 1,018.60 HAWORTH,Constance(Widow) $2,910.13 2,910.13 HAWORTH,Jack(Firefighter) $3,191.50 - 3,191.50 HENRY,William,Jr.(Captain) $1,339.58 1,339.58 HURST,Gerald(Firefighter) $543.59 543.59 JONES,Evelyn M.(Widow) $250.62 250.62 LARSON,William(Firefighter) - - LAVALLEY,Theodele(Captain) $360.94 360.94 MATTHEW,James(Deputy Chiefl - - MC LAUGHLIN,JACK(Battalion Chiefl $1,002.95 1,002.95 NEWTON,Gary(Lieutenant) $273.45 273.45 NICHOLS,Gerald(Battalion Chief) $536.08 536.08 PARKS-ANDREASON,Arlene(Widow) $335.32 335.32 PARKS,1ohn(Firefighter) $3,312.50 57.56 3,370.06 PHILLIPS,Bruce H.(Deputy Chief� $257.12 257.12 PRINGLE,Arthur(Captain) $481.28 481.28 PRINGLE,S.Joan(Widow) $2,500.14 2,500.14 RIGGLE,David E.(Firefighter D Step) $82.78 82.78 RUPPRECHT,1im(Firefighter D Step) $117.72 117.72 SMITH,Leroy(Firefighter) $409.86 409.86 STROM,Doris(Widow) $3,191.50 3,191.50 TODD, Franklin(Firefighter) $469.71 469.71 TONDA,Lila Jean(Widow) $8.43 8.43 VACCA,Nick(Lieutenant) $311.71 311.71 WALLS,Camille(Widow) $145.64 145.64 WALLS,Mercedes(Widow) $115.77 115.77 WALSH,David(Firefighter) $1,065.19 1,065.19 WEISS,Cheryl(Widow) $768.23 768.23 WILLIAMS,Alta(Widow) - - WOOTEN,Marilyn E.(Widow) $239.28 239.28 �Total Expenses:.Pension[IVledical .. -- , $35,571.71=: y-�=-$789.26 . _=$36,360t97 * Received funeral expenses of$500.00 per RCW 41.18.140. Prior Year Pension/Medical Payments: Total Pension Payments for February,2009 41,526.62 Total Medical Bilis Reimbursed in February,2009 1,592.88 Totai Expenses: Medical/Pension 43,119.50 4_SUMMARY 2010.XLS 02/12/2010 �' � FIREMEN'S PENSION BOARD MEDICAL BILLS TO BE REIMBURSED IN FEBRUARY, 2010 PAYMENT Page ' �Nairte PharmaG 1Metlical Facili Date . .=; �rAmount of:Bil( James Ashurst 0.00 2 Charles Goodwin Bartell Drugs 12/23/09 30.05 2 Charles Goodwin Bartell Drugs 12/23/09 194.36 2 Charies Goodwin Bartell Drugs 01/16/10 9.89 2 Charles Goodwin Bartell Drugs 01/24/10 211.10 3 Charles Goodwin Bartell Drugs 01/24/10 30.05 3 Charles Goodwin Bartell Drugs 01/25/10 171.70 3 Charles Goodwin Bartell Drugs 01/25/10 36.89 4 Charles Goodwin Bartell Drugs 12/28/09 10.79 4 Charles Goodwin Bartell Drugs 12/28/09 17.99 4 Charles Goodwin Bartell Drugs 01/25/10 10.79 4 Charles Goodwin Bartell Drugs 01/29/10 8.09 731.70 Jack Haworth 0.00 6 John Parks Olympic Drug 12/14/09 6.28 6 John Parks Olympic Drug 01/03/10 7.00 6 John Parks Olympic Drug 01/03/10 7.00 6 John Parks Olympic Drug 01/03/10 5.00 6 John Parks Olympic Drug 01/29/10 5.00 6 John Parks Olympic Drug 01/29/10 7.00 6 John Parks Olympic Drug 01/29/10 6.28 6 John Parks Olympic Drug 01/29/10 7.00 6 John Parks Olympic Drug 01/29/10 7.00 57.56 =TOT�E. , ; ` ' � - �,789.26 3_2010 FP Medical,XLS Page 1 of 1 o?J1212o10 `"�'" SENDCLAIMTO: `�r'' City of Renton Finance Dept.-Fire Pension 1055 South Grady Way Renton,WA 98057 Oti�Y �� + � ♦ "��'N�� CITY OF RENTON FIREMEN'S PENSION BOARD Pharmacy/Medical Claim Reimbursement Request 1) DATE � _ 2) DISABILITY RETIREE'S NAME (print)�',��-� T`f= �C�'Cyl�CC�e ll� 3) ADDRESS f�l� '`��« (�� /V � ��i�.�, ��'�l�r ��,� 4) DISABILITY AT TIME OF RETIREMENT��'� ��CJ�%'7"/�� Tf��`��iL'i(1 5) DESCRIPTION OF CLAIM: (Supporting documentation must be attached.) ' (Effective 4/1/2008,pre-LEOFF retirees may submit all prescription drug ezpenses for reimbursement, whether or not related to the retirement disability,provided that the ezpense is not covered by another plan,source or insurance coverage. Supporting documentation for all must be attached.) �� ,� 6) TOTAL AMOUNT OF CLAIM: $ ��! • ��(� Amount of total claim(above) that is related to the Retirernent Disability: $J�� 7) I certify that I have not been and will not be compensated by any other organization, insurance carrier or Medicare for the above-mentioned claim for reimbursement other than the City of Renton. I further certify that the above statements are complete and accurate to the best of my knowledge, and that any charges other than prescription drug charges, are related to my disability as determined at the time of my retirement from the Renton Fire Department. � 1 / - Signature: Note: Supporting documentation must be attached. �� f ��r ��s�� ! - ' .� , � . �z.��--��, � _ ,.�� ,�- �- � �► . � 1�- BART LE L � • � BARTELL � � ��Wmh:ngtoa'i OmnDnrgstoru�.� Warhingtoa a Oron Drugston+�� 45-520381 E o�. FLO, GAYLE '�" 45- 515918 E o� LORCH,GERALD oATE� 12/23/09 R (425)251-5110 oarE: 12/23/09 R (425)251-5110 N,�n�+E: CHARLES GOODWIN N�E� CHARLES GOODWIN 1414 MONROE AVE NE#306 1414 MONROE AVE NE#306 GEMFIBROZIL 600MG TABLET(*CA AGGRENOX CAP 200/25 31722-0225-05 7837090994659 00597-0001-60 7837094574659 REFILL � QUANTITY sO.00 (\� REFILL '2 QUANTffY 60.00 BARTELL DRUGS PRICE_ $33.39 � V BARTELL DRUGS PRICE_ $208.99 / t��' WITH SR THE AMO / WITH SR THE AMOUNT DUE- 194.36 UNT DUE 30.05 � � � BARTELL DRUGS#45 BARTELL DRUGS#45 (425)793-1015 (425)793-1015 4700 NE 4TH STREET 4700 NE 4TH STREET RENTON,WA 98059 RENTON,WA 98059 THANK YOU THANK YOU WE TRULY APPpECIATE YOUfl BUSINESS. TO PROVIDE YW WE TRULY APPRECIATE YOUR BUSINESS. TO PROVIDE YOU WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR N11TH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR � REFILLS 2448 HOURS IN ADVANCE L REFILLS 24-48 HOURS IN ADVANGE � BARTELL � ' _ _ .��Washington'+Oum DrugsWr rew��• �� 45- 519637 E oR• LORCH,GERALD BARTELL � � � oaTe: 01/16/10 R (425)251-5110 �n`w'`�^g`°"'1Oe°"D'"`.'""'-- Rx# 45- 515918 E nR. LORCH,GERALD wanne: CHARLES GOODWIN DATE: 0��24I�O R (425)251-5110 1414 MONROE AVE NE#306 � NaME: CHARLES GOODWIN ALLOPURINOL 100MG TABLET(*Q/ 1414 MONROE AVE NE#306 00603-2115-32 6483605247609 AGG NOX CAP 200/25 ,�F�,� Np QUEwrm� 30.00 (�� 00597-0 01- 3186996668709 BARTELL DRUGS PRICE_ $10.99 �.V REFILL � Qunrvrrrr 60.00 WITH SR THE AMOUNT DUE- 9.89 ,,/ BARTELL DRUGS PRICE_ $226.99 � ��/j BARTELL DRUGS#45 WITH SR THE AMOUNT DUE= 211.10 / (425)793-1015 ,/ 4700 NE 4TH STREET BARTE�L DRUGS#45 RENTON,WA 98059 (425)793-1015 4700 NE 4TH STREET THANK YOU RENTON,WA 98059 WE TRULY APPRECIATE YOl7R BUSINESS_TO PROVIDE YOU WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR THANK YOU REFILLS 24-48 HOURS IN ADVANCE � WE TRULY APPRECIATE YOUR BUSINESS. TO PROVIDE YOU - WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR L REFILLS 24-48 HOURS IN ADVANCE i� � �� v / �, � � 3 /0 �J . �.v /� � ��C�G!��1<";�� , ' + f/{j,�� - �� I/��`t1i�1�T"' � L��t�i�l.� ��, C� �. � BARTELL � ' �ypcshington4 O�on Dru6dore��"�� R� 45- 520381 E oR• FLO, GAYLE oare: 01/24/10 R (425)251-5110 r,aMe: CHARLES GOODWIN 1414 MONROE AVE NE#306 GEMFI OZIL 600MG TAB3 984oas5s 00093 0670- 5 - BA�TELL � ' REFILL NO QUANTITY 6�.�� Wm �nglon'iOmnDrugstarci BARTELL DRUGS PRICE_ $33.39 �� 45- 535806 E oR� KATO DATE: O�/L�J/�O N (425)255-9310 WITH SR THE AMOUNT DUE= 3�,0•U5 �,ME: CHARLES GOODWIN BARTELL DRUGS#45 1414 MONROE AVE NE#306 (425)793-1015 4700 NE 4TH STREET LISINOPRIL 5MG TABLET(MYL)- 10 RENTON,WA 98059 00378-2073-10 8464228964659 THANK YOU REFILL 2 nunrrrirr 100.00 � � �� WETRULYAPPRECIATEYOURBUSINESS.TOPflOVIDEYOU gARTELLDRUGSPRICE= $40.99 WITH THE BRE ILLS 24-48 HOURS N ADVANCE DER YOUR ' �� - WITH SR THE AMOUNT DUE= 36.89 BARTELL DRUGS#45 _ (425)793-1015 BARTELL � � 4700 NE 4TH STREET .��{VoshingtonlO�unDniptore�----- � RENTON,WA 98059 �# 45- 508468 E oR. BORROMEO-WES 425 899-3123 TiiANlC YOiJ DATE: O�IZ�J/�O R � � ' WE TRULY APPRECIATE YOUR BUSINESS. TO PROVID�YOU r,aMe: CHARLES GOODWIN WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR � REFILLS 24-48 HOURS IN ADVANCE , 1414 MONROE AVE NE#306 CARBIDOPAILEVODOPA 25MG/100M 00228-2539-10 00005137972001 � REFILL � aunrrnn' 540.00 � . � BARTELL DRUGS PRICE_ $848.89 � �'`� �� WITH NEW THE AMOUNT DUE= 171.70 � BARTELL DRUGS#45 �Q �p (425)793-1015 � 4700 NE 4TH STREET RENTON,WA 98059 THANK YOU WE TRULY APPRECIATE YOUR BUSINESS.TO PROVIDE YOU WITH THE BEST SERVIGE POSSIBLE;PLEASE ORDER YOUF REFILLS 24j[B HOURS IN ADVANCE � L ~ / �� 3 �, � � /Q , - � " �� ., r �,�' �J/�//� f �j��;�� . ��.C/ /� � � � � � VV BARTELL � � — —w�.h:n�on�.�no��.�a.�. BARTELL � • � C 45- 529808 E oR. E(qT0 ��a�+, wn ,,�,g,�o„�..�. oA�� 12/28/09 R (425)255-9310 '� C45- 535807 E DR. �TO N,on�E: CHARLES GOODWIN DATE: O�IZJ�I�O N (425)255-9310 1414 MONROE AVE NE#306 NA�E: CHARLES GOODWIN 1414 MONROE AVE NE#306 �, HYDROCODONE/APAP 5MG/500MG �.� 00591-0349-05 00004934858201 HYDROCODONE%APAp 5MG/500MG � 00591-0349-05 00005136876401 � REFILL NO QUANTITY sO.00 �� `,( i/� 1 BARTELL DRUGS PRICE_ $37.39 /�"► REFILL NO Qunrm-rv 60.00 1 V'� ' ,o' {/ BARTELL DRUGS PRICE_ $37.39 ti WITH NEW THE AMOUNT DUE= 10.79 / d WITH NEW THE AMOUNT DUE= 10.79 �' BARTELL DRUGS#45 (425)793-1015 BARTELL DRUGS#45 4700 NE 4TH STREET (425)793-1015 i�' RENTON,WA 98059 4700 NE 4TH STREET % RENTON,WA 98059 �� THANK YOU i WE TRULY APPRECIATE YOUR BUSINESS. TO PROVIDE YOU THANK YOU / WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR WE TRULY APPRECIATE YOUR BUSINESS. TO PROVIDE YOU i REFILLS24-48 HOURS IN ADVANCE � WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR ` L REFIL�S 2448 HOURS IN ADVANCE ( ! ' % _ � BARTELL � - BARTELL � - ��Waahirsgton's purn Drugatoree�� C45- 507730 E oR. GRIFFITH,ALIDA �"°''"'�°n%�nD�.�«�•---- DATE: ��28�09 R (425�ggg_3�23 '� C45- 536660 E oR. GRIFFITH,ALIDA NAME: CHARLES GOODWIN DATE: 0��29��0 N (425) 899-3123 1414 MONROE AVE NE#306 NAME: CHARLES GOODWIN �%'"" ' ZOLPIDEM 5MG TABLET(DRR) 1414 MONROE AVE NE#306 r� 55111-0478-01 7895994314659 Z 1D`EI�1 'S�p(IG TABLET(DRR) 5 11-0478-01 `' 00005172895501 �J „��{�"'�f✓ '°` ` REFILL � QUANTITY 30.00 -J�5 �, � L�- �1' REFILL rj QUANTITV LfJ BARTELL DRUGS PRICE_ $19.99 30.00 WITH SR THE AMOUNT DUE= 17.99 BARTELL DRUGS PRICE_ $142.69 • BARTELL DRUGS#45 W�TH NEW THE AMOUNT DUE= 8.09 �_ `J , (425)793-1015 BARTELL DRUGS#45 � 4700 NE 4TH STREET (425)793-1015 RENTON,WA 98059 4700 NE 4TH STREET L��. � RENTON,Wq g8059 T'HANK YOU WE TRULY APPRECIATE YOUR BUSINE55. TO PROVIDE YOU THANK YOU � WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR WE TRULY APPqECIATE YOUR BUSINESS. TO PROVIDE YOU .j _ REFILLS 24-48 NOURS IN ADVANCE WPfH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR �1� � L REFILLS 2448 HOURS IN ADVANCE ( �� , - .��,� L� �� l `�' SENDCLAIMTO: �' City of Renton Finance Dept.-Fire Pension 1055 South Grady Way Renton, WA 98057 OS�Y �� ♦ � " + � ��N`�°� CITY OF RENTON FIREMEN'S PENSION BOARD Pharmacy/Medical Claim Reimbursement Request 1) DATE ��, � lI t b 2) DISABILITY RETIIZEE'S NAlV�(print) r � .� 3) ADDRESS J � �'.�t � �,r � , � � L `�II 4) DISABILITY AT TIME OF RETIREMENT �`��j �p��Va° �� ,?.�� -l�'"�� rJ r U' �n r��% t cv.�'i j/ P-�`a�J•e�s � 5) DESCRIPTION OF CLAIM: (Supporting documentation must be attached.) (Effective 4/1/2008,pre-LEOFF retirees may submit all prescription drug expenses for reimbursement, whether or not related to the rehrement disability,provided that the egpense is not covered by another plan,source or insurance coverage. Supporting documentation for all must be attached.) 6) TOTAL AMOLTNT OF CLAIM: $ ,�rj, ��_ Amount of total claim(above) that is related to the Retirement.Disability: $ �� 7) I certify that I have not been and will not be compensated by any other organization, insurance carrier or Medicare for the above-mentioned claim for reimbursement other than the City of Renton. I further certify that the above statements are complete and accurate to the best of my knowledge, and that any charges other than prescription drug charges, are related to my disability as determined at the time of my retirement from the Renton Fire Department. _ Signature: Note: Supp ing documentation must be attached. �� MP/COR1/Qi RECEIPT 12441b1hAve. Lon ew WA98632 Ph.(360)423-33B0 SAVEFORINSURANCE ��"�"�B� RECEIPT ' axu C9�4�95 Fo�: JOHN PARKS ORTAXRECORDS �"J"��M�QnV� CNN:A8097481386871 �r�.��`�� -SAVE FOf�INSURANCE 12•14-09 1335 3RD AVE M109 OR TAX RECORDS 1244 75th w,WA98632 Ph.(360)423 3360 LONGVIEW,WA 98632 I360) 577•6684 px� �� Fo�: JOHN PARKS . ALPRAZOLAM 0.5MG TAB *** 1•29•10 CflN:A4104296018781 13353RDAVE/i109 � LONGVIEW,WA 98632 (360) 577•6684 #60 NDC: 59762-3720-03 DR. RICHARDS,JOHN E ZHA COPAY: $6.28 OMEPRAZOLE CAP 20MG *�* IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIII P�� DRsRICHARDs JOHNEa•s,50-,o ZHp COPAY: $7.00 �.,�e,�,h�sm,,;�e.o. —� IIIIIIIIIIIIINIIIINIIIIIIIIINIIIIIINIIIIIIIIINI4111NIIIIINNNIIIIIIIIIINIIIIIIIIIIIIIIIIIII P�� p�� RECEIPT SAVE FOR INSURANCE RECEIPT 1244151h Ave. Lon ew,WA98632 Ph.(360)423-3360 OR TAX RECORDS �eseea. `v° Rx� 91 b9�8 For: JONN PARKS '''v'��M��jj��■ 1•03-10 CFN:A2104030387141 1335 3RD AVE/t109 SAVE FOR iNSURANCE LONGVIEW,WA 98632 (360� 577-6684 j��15�th Ave.,Longview,WA 98632 Ph.(360)423-3360 OR TAX RECORDS LACTULOSE SOL 10GMI15 S - p,� C934595 For. JOHN PARKS #473 NDC: 00603-1378•58 CflN:A7104292828631 1335 3RU AVE N109 DR. RICHARDS,JOHN E ZHA COPAY: $�.00 1•29•10 LONGVIEw,WA 98632 13601 577-6684 � IIIIIIII IIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII P�CO A#60�°�NM:°97MG20oB *** DR. RICHARDS,JOHN E ZNA COPAY: $6•28 �.�� ,�h �° �°. 1 illillillllllllilllllllllillllll�llllllllll�llllllllllllll�llillllllilllllillllililllllllllllllll P�� Ylrl ��m ��I�fi RECEIPT ' SAVE FOR INSURANCE 1244 75th Ave.,Lon ew,WA 98832 Ph.(360)423,3360 OR TAX RECOR�S °'�1e*"'�""""�'D' Rx� 9345�6 For: JONN PARKS �YIrIp1�ORY6 RECEIPT 1•03•10 CBN:A7104032031D81 1335 3RD AVE/J109 � �'�` �� SAVE FOR INSURANCE 124415th v ew,WA 98632 Ph.(360)423-3360 LONGVIEW,WA 98632 1360) 577-6684 pXp 't� �� For. JOHN PARKS aR rnx RecoR�s MIRTAZAPINE SOLTAB 45MG �.29.�p CflN:A9104282853381 13353RDAVEM109 #30 NDC: 65862•0023-06 LONGVIEW,WA 98632 (360) 577•6684 DR. RICHARDS,JOHN E ZHA COPAY: $�.00 LACTULOSE SOL 10GMI15 S IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII Pf16B R4R CHARDSDJOHNSE3•1378•58 ZHA COPAY: S�.00 �Pweo<<h�.mumo.o. 1 ��I��I��II��I��I��I��I��I��I��I��I��I��I�� Pdce �=' OIIV�i RECEIPT � � 124415th Ave.Lon ew,WA98632 Ph.(960)423-3380 SAVE FOR INSURANCE C9�4�01 ORTAXRECOflDS �Ma» '�° Rx� Foc JOHN PARKS ��M��j��j RECEIPT �. 1•03-10 CBN:A21o4o338755t 1 1335 3RD AVE N109 12qq�5th v . n v'ew,WA 98632 Ph.(360)423-3360 SAVE FOR INSURANCE **�LONGVIEW,WA 98632 �360� 577-6684 RMp ��,�,�� Fo,: JOHN PARKS ORTAXRECORDS � ZOLPIDEM TAB 10MG 1-29•10 CflN:A2104287716371 1335 3RD AVE q1�9 � #30 NDC: 00378•5310-05 LONGVIEW,WA 98632 �3601 577-6684 I DR. RICHARDS,JOHN E ZHA COPAY: $5.00 MIRTAZAPINE SOLTAB 45MG IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII�IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII #30 NDC: 65862-0023-06 � �, Pdce DR. RICHARDS,JOHN E ZHA COPAY: S7.OQ , �� 1 I�IIIIIIIIIIIIIII�IIIIII�IIIII�IIIIIIIIII�IIIIIII��IIIIIIIIIIIIIII�IIII�IIIIIIIIIIIIIII�IIIIIIIIII� P�� .YM OR11� RECEIPT 124415th�v�.�,}.p�Qvj@�,WA 98632 Ph.(360)423-3360 SAVE FOR INSURANCE BzJ! �q�bV for. JOHN PARKS �RTAXRECORDS 1•29•10 CRN:A7104281075081 1335 3RD AVE#109 LONGVIEW,WA 98632 (360) 577•6684 ZOLPIDEM TAB 10MG �** #30 NDC: 00378•5310-05 � DR. RICHARDS,JOHN E ZHA COPAY: $S.00 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII II IIIIII(III I)IIIIIIIIIIIIII PrfCe