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Home My WebLink AboutFinal Agenda Packet CITY OF RENTON FIREMEN'S PENSION BOARD Regular Meeting 7th Floor-Mayor's Conference Room Thursday, October 21, 2004 3:30 P.M. 1. CALL TO ORDER 2. APPROVAL OF MINUTES OF SEPTEMBER 16, 2004 3. CORRESPONDENCE 4. MONTHLY STATEMENT TO 9/30/2004 5. MONTHLY BILLS AND PENSION PAYMENTS 6. UNFINISHED BUSINESS 7. NEW BUSINESS 8. ADJOURNMENT MINUTES FIREMEN'S PENSION BOARD CITY OF RENTON September 16, 2004 Kathy Keolker-Wheeler, Mayor Randy Corman, Council Finance Committee Chair Bonnie Walton, City Clerk Ray Barilleaux, Fire Department Representative William Henry, Fire Department Representative William Larson,Fire Department Alternate The regular meeting of the Firemen's Pension Board was called to order by Chairman Kathy Keolker-Wheeler at 4:00 p.m. in the Mayor's conference room, 7th floor of Renton City Hall. In attendance were Board members Kathy Keolker-Wheeler, Ray Barilleaux and Bonnie Walton; and Jill Masunaga, Finance Department Representative. MINUTES APPROVAL MOVED BY BARILLEAUX, SECONDED BY WALTON,THE PENSION BOARD APPROVE THE MINUTES OF THE AUGUST 19, 2004, MEETING. CARRIED. MONTHLY STATEMENT The financial report as of August 31, 2004, was reviewed. Total cash/investment balance was $4,957,735.87. MONTHLY BILLS AND PENSION PAYMENTS MOVED BY BARILLEAUX, SECONDED BY WALTON,THE BOARD APPROVE THE PENSION/MEDICAL PAYMENTS FOR SEPTEMBER 2004, IN THE TOTAL AMOUNT OF $32,030.93. CARRIED. ADJOURNMENT MOVED BY BARILLEAUX, SECONDED BY WALTON, THE MEETING OF THE FIREMEN'S PENSION BOARD BE ADJOURNED. CARRIED. Time: 4:10 p.m. ettlyt4wt, ( Lt Bonnie I. Walton, City Clerk Member and Secretary, Firemen's Pension Board , CITY OF RENTON - FIREMEN'S PENSION FUND CASH & INVESTMENT ACTIVITY REPORT AS OF SEPTEMBER 30, 2004 Fireman's Pension Fund Comparison of Cash and Investment Activity 6 ❑2004 ®2003 _ ; I 0 4 1, c E, Hi C 3 '1 2 l Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec CURRENT 2004 2004 LAST YEAR 2003 2003 ACTIVITY: MONTH YTD BUDGET CURR MO YTD ADJ BUDGET BEGINNING CASH/INV BALANCE $4,957,735.87 $5,133,315.47 $5,133,315 $5,140,827.65 $5,312,164.41 $5,312,164 RECEIPTS: Property Taxes 0.00 0.00 $0 0.00 0.00 $0 Fire Insurance Premium Tax 0.00 70,249.69 $40,000 0.00 63,087.83 $32,000 Investment Interest 267.75 9,641.43 $110,000 685.66 10,568.05 $115,000 DISBURSEMENTS: Fire Pension 30,932.24 281,598.00 $375,000 28,870.67 264,132.83 $355,000 Office/Operating Supplies 0.00 69.21 $400 69.09 206.91 $400 Actuarial/Firemen's Pens 0.00 0.00 $0 0.00 4,575.00 $4,000 Reimb General/Clerical&Acct 558.00 5,026.00 $6,700 542.00 4,874.00 $6,500 ENDING CASH/INV BALANCE $4,926,513.38 $4,926,513.38 $4,901,215 $5,112,031.55 $5,112,031.55 $5,093,264 CURRENT PREVIOUS LAST YEAR LAST YEAR ACTIVITY: MONTH MONTH CURR MO PREV MO CASH $17,882.30 $49,104.79 $37,493.49 $66,289.59 INVESTMENTS CD's&State Investment Pool 479,767.46 479,767.46 749,767.46 749,767.46 Snohomish County Housing Authority 0.00 0.00 98,272.00 98,272.00 Federal National Mortgage Assn 99,555.84 99,555.84 0.00 0.00 Treasury Strips&Zero Coupon Bonds 4,329,307.78 4,329,307.78 4,226,498.60 4,226,498.60 Corporate Bonds 0.00 0.00 0.00 0.00 Convertable Bonds 0.00 0.00 0.00 0.00 Mutual Funds 0.00 0.00 0.00 0.00 TOTAL CASH AND INVESTMENTS $4,926,513.38 $4,957,735.87 $5,112,031.55 $5,140,827.65 The State Investment Pool interest 1.5181% 1.3073% 1.0651% 10620 H:\FINANCE\FINPLAN\FIREPEN\2003 Fire Pension\1_Fire_Pension_2003.xls Page 1 10/8/2004 FIREMEN'S PENSION BOARD PENSION/MEDICAL PAYMENTS FOR OCTOBER, 2004 Recipient Pension Amt Medicals Total ANKENY, Charlie (Captain) $83.60 83.60 ASHURST, James (Assistant Chief) $3,927.00 - 3,927.00 BANASKY, George (Captain) $830.82 830.82 BEATTEAY, Karlen (Widow) $173.27 173.27 BERGMAN, Claudette (Widow) $107.78 107.78 CHRISTENSON, Chuck(Firefighter) $256.48 256.48 COLOMBI, Jack (Captain) $351.97 351.97 CONNELL, Robert(Captain) $604.89 604.89 GOODWIN, Charles (Captain) $3,563.00 - 3,563.00 GOODWIN, Donald (Firefighter) $835.12 835.12 HAWORTH, Constance (Widow) $2,472.05 2,472.05 HAWORTH, Jack (Firefighter) $2,688.00 805.42 3,493.42 HENRY, Teresa A. (Widow) $235.62 235.62 HENRY, William, Jr. (Captain) $1,099.60 1,099.60 HURST, Gerald (Firefighter) $436.61 436.61 JONES, Gerald D. (Firefighter) $188.09 188.09 LAVALLEY, Theodele (Captain) $274.95 274.95 MC LAUGHLIN, JACK(Battalion Chief) $656.13 656.13 NEWTON, Gary (Lieutenant) $204.14 204.14 NICHOLS, Gerald (Battalion Chief) $286.52 286.52 PARKS-ANDREASON, Arlene (Widow) $255 17 255.17 PARKS, John (Firefighter) $2,789.50 262.77 3,052.27 PHILLIPS, Bruce H. (Deputy Chief) $15.71 15.71 PRINGLE, Arthur(Captain) $376.80 376.80 PRINGLE, S. Joan (Widow) $2,123.77 2,123.77 RIGGLE, David E. (Firefighter D Step) $46.81 46.81 SMITH, Leroy (Firefighter) $325.09 325.09 STROM, Karl (Firefighter) $2,688.00 - 2,688.00 TODD, Franklin (Firefighter) $375.94 375.94 VACCA, Nick(Lieutenant) $238.36 238.36 WALLS, Kenneth (Firefighter D Step) $98.89 98.89 WALSH, David (Firefighter) $874.71 874.71 WALSH, Patrick (Captain) $804.52 804.52 WEISS, Larry (Battalion Chief) $463.47 463.47 WOOTEN, Marilyn E. (Widow) $179.86 179.86 Total Expenses: Pension/Medical 30,932.24 1,068.19 32,000.43 Prior Year Pension/Medical Payments: Total Pension Payments for October, 2003 28,870.67 Total Medical Bills Reimbursed in October, 2003 1,414.51 Total Expenses: Medical/Pension 30,285.18 4_SUMMARY 2004 10/8/2004 10:21 AM FIREMEN'S PENSION BOARD MEDICAL BILLS TO BE REIMBURSED IN OCTOBER, 2004 PAYMENT Page Name Pharmacy/Medical Facility Amount of Bill James Ashurst 0.00 Charles Goodwin 0.00 2 Jack Haworth Harbor Drug Co. 26.98 2 Jack Haworth Harbor Drug Co. 28.98 2 Jack Haworth Harbor Drug Co. 11.98 2 Jack Haworth Harbor Drug Co. 9.98 2 Jack Haworth Harbor Drug Co. 24.98 2 Jack Haworth Harbor Drug Co. 28.98 2 Jack Haworth Harbor Drug Co. 13.98 2 Jack Haworth Harbor Drug Co. 24.98 3 Jack Haworth Harbor Drug Co. 19.98 3 Jack Haworth Harbor Drug Co. 26.98 3 Jack Haworth Harbor Drug Co. 124.98 3 Jack Haworth Harbor Drug Co. 28.98 3 Jack Haworth Harbor Drug Co. 28.98 3 Jack Haworth Harbor Drug Co. 24.98 3 Jack Haworth Harbor Drug Co. 24.98 3 Jack Haworth Harbor Drug Co. 12.98 4 Jack Haworth Harbor Drug Co. 28.98 4 Jack Haworth Harbor Drug Co. 26.98 4 Jack Haworth Harbor Drug Co. 28.98 4 Jack Haworth Harbor Drug Co. 24.98 4 Jack Haworth Harbor Drug Co. 28.98 4 Jack Haworth Harbor Drug Co. 15.98 4 Jack Haworth Harbor Drug Co. 26.98 4 Jack Haworth Harbor Drug Co. 24.98 5 Jack Haworth Harbor Drug Co. 24.98 5 Jack Haworth Harbor Drug Co. 28.98 5 Jack Haworth Harbor Drug Co. 24.98 5 Jack Haworth Harbor Drug Co. 26.98 5 Jack Haworth Harbor Drug Co. 28.98 Jack Haworth Hearing Aid Consultants 0.00 805.42 7 John Parks Olympic Drug 46.49 7 John Parks Olympic Drug 23.85 7 John Parks Olympic Drug 22.58 7 John Parks Olympic Drug 169.85 262.77 Karl Strom 0.00 TOTAL 1,068.19 3_2004 FP Medical 10/8/2004 10:20 AM rr✓ SEND CLAIM TO: City of Renton Finance Dept.-Fire Pension 1055 South Grady Way Renton, WA 98055 O�CY 0 TiR ANT° CITY OF RENTON FIREMEN'S PENSION BOARD Pharmacy/Medical Claim Reimbursement Request 1) DATE °a l74 10+ 2) DISABILITY RETIREE'S NAME(print) clM%K, A Ol4 3) ADDRESS 4) DISABILITY AT TIME OF RETIREMENT 5) DESCRIPTION OF CLAIM: (Supporting documentation must be attached.) (Note: Medical coverage is limited to current treatment of the retiree's disability as determined at the time of retirement. (RCW 41.18) Submit only claims that relate to item#4.) 6) TOTAL AMOUNT OF CLAIM soc, �Z 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 ether than the City of Renton. I further certify that the above statements are complete and accurate to the best of my knowledge, and that all claims submitted are related to my disability as determined at the time of my retirement from the Renton Fire Department. Signature: Note: Supporting documentation must be attached. F,66EI i Harbor Drug C prescriptions . . .t Harbor Drug Co.PriptionS Ti' 316 8th St Phone 360-532-3061316 8th St. a 360-532-3061 WA 98550 24 W.Rx Refill(3601538.8878 Hoquiam,WA 98550 24 Hr.Rx Refill(360)53&9978 vonoctararaa.r •Pdab.redaragoeyp.mcu.r.,c+rIarwmmpwwpa """.eta." `°"e`"`dwa°b.rymon ortenp."`"stanpr".b.` KONN 1ONN RX#C 555853 R RX# 549660 R DR. MORRIS /24/04 LL • 1/12/04 DS HAWORTH,JACK HAWORTH,JACK BOX 864,OCEAN SHORES,WA 98551 BOX 864,OCEAN SHORES,WA 98551 LORAZEPAM 1 MG LEVOTHROID 0.1MG TABLET QTY#60 NDC#00456-0323-00 QTY#30 NDC#00781-1404-10 GENEV $29.77 ; 4 REFILLS '� m ..„ NO REFILLS DISC- $2.79 PRICE: $26.98 PRICE: $24.98 111111111P11110111 11111111 111111111111111111111111111 ,, RECEIPT RECEIPT DescrHarbor C11pruumb . Pr iptions ',' 316 8th St. Phone 360.532-3061 1`r. 316 8th St Phone 360-532-3061 Hoqulam,WA 98550 24 Hr.Rx Refill(360)538.9978 = Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 for whdnpasatat WAPPING:Stals aFed.dlaw pnmbbtra..deesdug b enypen=°Rsmenp.xt*"wham presabed al n51g3 tr'Rd"15117M§ ( RX# 551293 R DR. MORRIS 2/21%04 DS 1/21/04 DS HAWORTH,JACK HAWORTH,JACK BOX 864,OCEAN SHORES,WA 98551 BOX 864,OCEAN SHORES,WA 98551 ISOSORBIDE MONO.30MG.ER ISOSORBIDE MONO.30MG. ER QTY#30 NDC#59930-1502-01 IDTY#30 NDC#59930-1502-01 $33.85 $33.85 MAY REFILL DISC- $4.87 MAY REFILL DISC- $4.87 PRICE: $28.98 PRICE: $28.98 11111111111III111IN11111111111111111111111111111I11111111111 III 1IMI III III IIIIII1111II1IIIIIIIIIIIIIIII11111III R111 RECEIPT RECEIPT 11 �� Harbor Drug Co.Prescriptions '' Harbor Drug Co.Prescriptions `� 316 8th St. Phone 360.532.3061 Alf 316 8th St. Phone 360-532-3061 % Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 Hoquiam,WA98550 24 Hr.Rx Refill(360)538-9978 WARrxeftState aFaawrlaw pamewm.MY.drug bwry pwemawrar patlentlor Ow presented RX# 5496 "":S or496-83 Rd9'15P MOR IS"' RX# 533203 R DR. RUYLE 2/17/04 DS 1/15/04 DSHAWORTH,JACK HAWORTH,JACK BOX 864,OCEAN SHORES,WA 98551 BOX 864,OCEAN SHORES,WA 98551 ERYTHROMYCIN OPTH OINT B&L FUROSEMIDE 20 MG QTY#4 NDC#24208-0910-55 QTY#60 NDC#00054-4297-31 $13.91 1 REFILLS $15.50 r4AAY REFILL DISC- $1.93 DISC- $1.52 PRICE: $11.98 PRICE: $13.98 II 11 I Mill lhill 1ii111111 '1111111 1111111 1.1111 III II11 I I II1111111III III SII 11111111111111111111111111 JACK HAWORTH RECEIPT 2 Harbor Drug Co.Prescr 22_ Harbor Drug Co.Prescriptions 1.. 316 8th St Phone 3605323061 Ti 316 8th St Phone 360-532-3061 . Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 Hoquiam,WA 98550 24 Hr.Rx Refill(�3�6d0t)538.9978 XR #C 55583 R dma v KNN � � Y1p--- rry KONn wham palated RX# 558283 N 2/23/04 DS 2/3/04 DS HAWORTH,JACK HAWORTH,JACK BOX 864.00EAN SHORES.WA 98551 BOX 864,OCEAN SHORES,WA 98551 LORAZEPAM 1 MG ' NITROSTATQTY#25 11150 NDC#SUBL0007QTY#30 NDC#00781-1404-10 GENEV 1-0570-13 P-D 3 REFILLS NO REFILLS PRICE: $24.98 PRICE: $9.98 I ( II I i �1 111111111111111111111111111111111111111 1�111111111i��1111111I111�1I �iI1I11I1I11111 I RECEIPT PA&C Y RECEIPT `— - - — • ,tt,, .•Harbor Drug Co.Press ',tions '‘i. Harbor Drug c escri l , t y 316 8th St. ?'3061 hone 360-532-3061 Hoquiam,WA 98550 24 Hr.Rxw�}RetillPqrg�e�e� 38-y9}9�7e6a 'ti 316 8th St i, r sp)$ �g RX#559669 Napae UK. tiV VHNI: t� :soya"al impaar�aamprio Rry puRweao�i Mg paM9aiat 2/23/04 DS RX# 551293 R DR. MORRIS HAWORTH,JACK 3/24/04 DS 1 BOX 864,OCEAN SHORES,WA 98551 ' HAWORTH,JACK I SILVER SULFADIAZINE CREAM BOX 864,OCEAN SHORES,WA 98551 QTY#50 NDC#49884-0600-58 PAR ISOSORBIDE MONO.30MG. ER QTY#30 NDC#59930-1502-01 1 REFILLS $21.92 $33.85 DISC- $1.94 MAY REFILL DISC-,$4.87 PRICE: $19.98 PRICE: $28.98 111 NIIIIIIIIIINNNNI IIINI"OIIIIII'IIIIIIIIIIIIIIIIIII1 IN l I�IIN I�III�NI I III IINIHIN h 1111I11I0IIIlin III RECEIPT RECEIPT AMMIIN HARBOR DRUG INC. EIPHarbor Drug Co. Prescriptions 316 8TH STREET HOQUIAM,WA 98550 316 8th St. Phone 360-532-3061 PHONE(360)532-3061 6:SlHeooquFeamaWr proA9tr55s0er of2th4o dHRaxpeRefill t360n 53w8-997b8ed RX# 561030 N DR. MORRIS 3/12/04 PN RX#C 555853 R DR. KONN HAWORTH,JACK 3/29/04 DS BOX 864,OCEAN SHORES,WA 98551 HAWORTH,JACK LEVO THYROXINE 0.1 MG BOX 864,OCEAN SHORES.WA 98551 QTY#60 NDC#00527-1345-10 LORAZEPAM 1 MG QTY#30 NDC#00781-1404-10 GENEV $29.97 MAY REFILL DISC - $2.99 PRICE: $26.98 2 REFILLS ( PRICE: $24.98 III 1111111111 11111IIIIIIII,IIIIIIIIIII�IINIINIIIII 1 IfiI 11111111111111111111110111111111111111111 11 _ J RECEIPT HARBOR DRUG INC. Harbor Drug Co. Prescriptions 316 8TH STREET HOQUIAM,WA 98550 316 8th St. Phone 360-532-3061 PHONE(360)532-3061 Hoquiam WA 98550 24 Hr.Rx Refill(360)538-9978 Annan:State or Federal lee prohibits transfer of this drug to any person other then person for whom prescribed. RX# 561311 N DR. DIETZ RX#C 555853 R DR. KONN 3/17/04 DS 4/29/04 DS HAWORTH,JACK HAWORTH,JACK BOX 864,OCEAN SHORES,WA 98551 PLETAL 100MG TAB BOX 864,OCEAN SHORES,WA 98551 QTY#60 NDC#59148-0002-16 LORAZEPAM 1 MG QTY#30 NDC#00781-1404-10 GENEV $129.98 2 REFILLS DISC- $5.00 1 REFILLS PRICE: $124.98 PRICE: $24.98 IIN 111111111 III II 111111 11E11 III III ill 11111 'II 11111i II III!I 1.1111I1111 II 11111111111111111 11111Ii I II Harbor Drug Co. Prescriptions 316 8th St. Phone 360-532-3061 HARBOR DRUG INC. Hoquiam WA98550 24 Hr.Rx Refill(360)538-9978 nnninU.State or Federal ler prohibits transfer of this drug to soy person other t an person far whom prescribed. 316 8TH STREET HOQUIAM,WA 98550 PHONE(360)532-3061 RX# 549683 R DR. MORRIS RX# 551293 R DR. MORRIS 4/29/04 DS 3/18/04 DS HAWORTH,JACK BOX 864,OCEAN SHORES,WA 98551 HAWORTH,JACK FUROSEMIDE 20 MG BOX 864.00EAN SHORES,WA 98551 ISOSORBIDE MONO. 30MG. ER QTY#60 NDC#00054-4297-31 QTY#30 NDC#59930-1502-01 $14.91 $33.85 MAY REFILL DISC- $1.93 E MAY REFILL DISC - $4.87 PRICE: $12.98 PRICE: $28.98 1 II MIINI NINNNNNNII II 111111111 a111N11N 11111101111111111111111011110111110111111111111 I • Pmcz , RECEIPT nal UUI UI ug lath rl CbUI I�Jt1U11, . . . A Harbor Drug Co. °~ascriptions 316 8th St. phone 360-532-3061 ' 316 8th St. ane 360-532-3061 Hoquiam,WA 98550 2 ix Refill(360)538-9978 Hoquiam,WA 98550 24 Hr.R,?th1(360)538-9978 WARNING:Slate or Federal law prohlbin transfer of Thuds nny person other than person for whom prescribed. :State or Feder.'law prohibits transfer of We dug to any pane Mbar than person for whom prescribed RX# 551293 R DR. MORRIS 4/20/04 DS RX# 551293 R DR. MORRIS HAWORTH,JACK HAWORTH,JACK 6/22/04 DS BOX 864,OCEAN SHORES,WA 98551 BOX 864,OCEAN SHORES,WA 98551 ISOSORBIDE MONO.30MG. ER ISOSORBIDE MONO.30MG. ER QTY#30 NDC#59930-1502-01 QTY#30 NDC#59930-1502-01 $33.85 $33.98 MAY REFILL DISC- $4.87 MAY REFILL DISC- $5.00 PRICE: $28.98I I PRICE: $2I.98 .III 11111111.111110111111111101111111111111111111111 III!I X1111111,1111I111111�i 111I 1111p1111111plip�lliill Ilii ll III 1111 RECEIPT 1 _ RECEIPT _.__ - Harbor Drug Co. Prescriptions Harbor brug 1,�. . .si,.11w•..:..* 316 8th St. Phone 360-532-3061 316 8th St. Phone 360-532-3061 Ho uiam WA 98550 24 Hr.Rx Refill 360 538-9978 ��N Hoquiam,WA 98550 24 Hr.Rx Refill(3 0)538-9978 q ( ) WARNING:Slate or Federal law prohthrn transfer of drug to any person other than person for whom prescribed. �ARNIN�.Stele w Federal law pioUbim Innsler of Ihm drop to any person oUer Un person for whom preuribed. RX# 561030 R DR. MORRIS 5/10/04 JR HAWORTH,JACK RX#C 568758 N DR. MORRIS BOX 864.00EAN SHORES,WA 98551 HAWORTH,JACK 7/8/04 JR LEVOTHYROXINE 0.1MG BOX 864,OCEAN SHORES,WA 98551 QTY#60 NDC#00527-1345-10 HYDROCODONE/APAP 5/500 QTY#30 NDC#00591-0349-05 $30.43 Generic For:HYDROCO/APAP 5MG/500MG MALL $18.95 MAY REFILL DISC— $3.45 1 REFILLS DISC— $2.97 PRICE: $26.98 PRICE: $15.98 11 Illi!11111!II'NIlpllll1n111111In1111111h1p111p1111 II Ilp!!!I!I llilIlll!llllilllpl!!lpll!IIIIIMIVliIIIIIIIIIIII!1!IIIII , . ._ oorGtaT RECEIPT Harbor Drug Co. Prescriptions 316 8th St. Phone 360-532-3061 Harbor Drug Co. Prescriptions Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 Phone 360-532-3061 R G'Stale or Federal law piohlbin Iransbr of this drug to any person other Than person for whom preacnbed. [ 316 8th St. A 98550 24 Hr.Rx Ref ill(360)538-9978 ¢¢�� Hoquiam, RX# 551293 R DR. MORRIS WANNImG:Slate or Federal law proNbin Iransbr of Uis dray to arc.'person ether then person for wham prescribed 5/22/04 DS HAWORTH,JACK DR. MORRIS BOX 864,OCEAN SHORES,WA 98551 RX# 561030 R 7/12/04 DS ISOSORBIDE MONO.30MG. ER HAWORTH,JACK QTY#30 NDC#59930-1502-01 BOX 864,OCEAN SHORES,WA 98551 LEVOTHYROXINE 0.1MG $33.98 1 QTY#60 NDC#00527 1345 10 MAY REFILL DISC- $5.00 $30.34 PRICE: $28.98 MAY REFILL DISC - $3.36 III iIIIIIIIIIIlll111111101110111111111111111 III RN " PRICE: I11IIII IIIIIIIlI RECEIPT RECEIPT ftHarbor Drug Co. Prescriptions ^ Harbor Drug Co. Prescriptions 316 8th St. Phone 360-532-3061 'N H09aT WA 98559 24 Hr.Rx Refill(360)538-9978 316 8th St. Phone 360-532-3061 Stale o e oral few pio ibils Trans m of this drug to any person other Than pars n for whom prasonbed. Hoquiam WA 98550 24 Hr.Rx Refill(360)538-9978 RX#C 555853 R DR. KONN Slate r Federal Ian prohibits Iranster of Ihm drug to any person other Than person for Whom preacnbed. 6' /04 DS HAWORTH,JACKDR. KONN BOX 864,OCEAN SHORES,WA 98551 RX#C 569004 N 7/12/04 DS LORAZEPAM 1 MG HAWORTH,JACK QTY#30 NDC#00781-1404-10 GE NEV BOX 864,OCEAN SHORES,WA 98551 LORAZEPAM 1MG QTY#30 NDC#00591-0241-10 NO REFILLS $29.42 PRICE: $24.98 5 REFILLS DISC — $4.44 . Il10011111111111111111111111111111111111111111 PRICE: $24.98 11111111111111111111I11I8NII pA66 LI- RECEIPT — ` — _RECEIPT`RECEIPT _ ' or um sem, ,..elr+r " Harbor Drug Co. Prescriptions Harbor Drug Co. Prescriptions \L 316 8th St. Phone 360-532-3061 316 8th St. Phone 360-532-3061 . Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 WARNING.Stae or Federal taw prohibhstransfer of this drug to any person other Man person for whom prescribed. Hoquiam,WA 98550 24 Hr. gt Rx Refill(360)538-9978 WARNING:Stale or Federal In prohibits vender of this drug Io any person other than person for whom prescribed. RX#C 569004 R DR. KONN RX# 561030 R DR. MORRIS HAWORTH,JACK 8/2/04 DS HAWORTH,JACK 9/13/04 DS BOX 864,OCEAN SHORES,WA 98551 LORAZEPAM 1MG BOX 864,OCEAN SHORES,WA 98551 QTY#30 NDC#00591-0241-10 LEVOTHYROXINE 0.1MG QTY#60 NDC#00527-1345-10 $29.42 $30.34 4 REFILLS DISC— $4.44 MAY REFILL DISC— $3.36 PRICE: $24.98 HIM 11111111100110111 IPIIII011I111 IIIIIIIIIIIIIM11!1II I IIIPRICE: $26.98 III 11.01111111011 III 11 1111 11 1111111111I 1111 I II I ii RECEIPT RECEIPT Harbor Drug Co. Prescriptions Prescriptions € 316 8th St. Phone 360-532-3061 Harbor Drug Co. 1p :511Pp{ l W/��9 t5 Q �4�Ir Rz Ref l�360��3�-997 r 316 8th St. - Phone 360-532-3061 4�;�erel law pro i i re sero Fera rugloaq persano ert an per n rw ora prescrl a Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 WARNING:State on Federal law prohibits transfer of this drug to any person other than person for whom prescribed. RX# 551293 R DR. MORRIS HAWORTH,JACK 8/23/04 DS RX# 551293 R DR. MORRIS BOX 864,OCEAN SHORES,WA 98551HAWORTH,JACK 9/20/04 DS ISOSORBIDE MONO. 30MG. ER BOX 864,OCEAN SHORES,WA 98551 QTY#30 NDC#59930-1502-01 ISOSORBIDE MONO. 30MG. ER QTY#30 NDC#59930-1502-01 $33.98 MAY REFILL DISC— $5.00 $33.98 PRICE: $28.98 MAY REFILL DISC — $5.00 III II?IIIIIIII!IV I�III IIIIIIIIIIIIIIIIIIiIIiIIIII MINI PRICE: $28.98 111111111111111111111111 IIli 11111111111111111 I. ----__ ,RECFIPT 4 L — — RECEIPT � Harbor Drug Co. Prescriptions 316 8th St. Phone 360-532-3061 Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 WARNING:Stele or Federal law prohibits transfer of this drug to any person other than person for wham prescribed. RX#C 569004 R DR. KONN HAWORTH,JACK 9/2/04 JR RX# 561030 7/12/04 DS BOX 864,OCEAN SHORES,WA 98551 BOX864HAWORTH;JACK 44`, LORAZEPAM 1MG BOX 864 ;,,', ,� 1= { QTY#30 NDC#00591-0241-10 OCEAN SHORES,WA 9851 May Refill DR. MORRIS _ ----- " AM8470130 $29.42 815 K ST.HOQUTAM"`9VA 93550 ,- 3 REFILLS DISC — $4.44 LEVOTHYROXINE 0.1MG.- # 60 PRICE: $24.98 NDC#00527-1345-10,- 111 111 IIIl11111111111110111I161'1l111111111111111111 Orig: 1/12/04 . PRICE: $26.98 �crcioT1111�11I1.11111II II 111 RX#-561030 DS 7/12/04 ,. HAWORTH,JACK X $26.98 P � SEND CLAIM TO: City of Renton Finance Dept.-Fire Pension 1055 South Grady Way Renton, WA 98055 O� 0 A .N`c° CITY OF RENTON FIREMEN'S PENSION BOARD Pharmacy/Medical Claim Reimbursement Request 1) DATE r 0 / "- 0 it 2) DISABILITY RETIREE'S NAME(print) NI 0 YL 91 ,L, Ti 1*-s 3) ADDRESS (33 6-' 4 vf 109 9 Lo rg tfi ew1 u/ei qW 63a 4) DISABILITY AT TME OF RETIREMENT `j/ c_7T cI Y 1 1 21 14 ( ---S-76 O 'YII4(�'`j, (f CC f 1 4 I -eP1vx ?n4 dnuie7y' pso(lle-ni 5) DESCRIPTION OF CLAIM: (Supporting documentation must be attached.) (Note: Medical coverage is limited to current treatment of the retiree's disability as determined at the time of retirement. (RCW 41.18) Submit only claims that relate to item#4.) 71 < l 71 f --PQM' , - eh 4114 d3 7t r 1 er )97,-b�'J e 7AS 6) TOTAL AMOUNT OF CLAIM R L 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 ether than the City of Renton. I further certify that the above statements are complete and accurate to the best of my knowledge, and that all claims submitted are related to my disability as determined at the time of my r ' ent from the Renton Fire Department. 3 )Signature: 4,-P44,* , . fetratfr Note: Supporting documentation must be attached. F NNW Value at the smiling'O' value at the smiling DRUG DRUG 1244 wwww15th«Arwve.,rLoanalew,e.,WA98832 ahrMP .(3660)423ss-336ea0 1244 ac15111,Ave.,4uzlew,x.941632 tat. 423-3360 • 54 DRmRICHARDS RX#C436684 DRnRICHARDS UNKNOW 9/15/04 DS UNKNOWN 9/15/04 DS PS, JOHN PARKS, JOHN 1�1�1 ►��Il��l�ii I��I 111111 lil�ln Ili1111111111111111111 MIRTAZAPINE 45MG TAB AMBIEN 10MG TABS#### QTY#30 NDC#00185-0222-30 QTY#50 NDC#00024-5421-50 WI NTH Generic For:REMERON 45MG TABS 2 REFILLS UNTIL: 7/14/05 1 REFILLS UNTIL: 3/14/05 PRICE: $46.49 PRICE: $169.85 II II 011111 III II II III II II IIsi II II II IN IIiN I Illill11111 III 11 ll illi ll It RECEIPT RECEIPT value at the smiling V' le), Vem W1N24✓P4q15AFovdoeot.,eiewda,aWM19632 ashnfe (3151,1F3-3360 RX# 412236 DRRICHARDS UNKNOWN 9/15/04 DS PARKS, JOHN innir'fl'flEnhiI 11f 1111.11 1.011111111 Il, METOCLOPRAMIDE TAB 5MG QTY#100 NDC#50111-0517-01 Generic For:REGLAN 5MG 2 REFILLS UNTIL: 6/7/05 PRICE: $23.85 1111111 II 11111101 11111111111 II RECEIPT valueatthe smiling'0' dew YH W1w24w4 1S5atbh1,AFovdse.,rLotriewtbr,We9up8632 Qrfmtle pe(36b0)4234a-3iw36be0 - RX#C436682 DRRICHARDS UNKNOWN 9/15/04 DS PARKS, JOHN 11�� 1�1��11 �I��I111'"11111 IIIIIUIIIIIIII ALPRAZOLAM 0.5MG TAB QTY#120 NDC#00228-2029-96 PUREP 2 REFILLS UNTIL: 3/14/05 PRICE: $22.58 Il 111111llllll l ill lllllll1111 11,1111 RECEIPT 1W' 1