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Home My WebLink AboutFinal Agenda Packet 'fir✓ vie CITY OF RENTON FIREMEN'S PENSION BOARD Regular Meeting 7th Floor-Mayor's Conference Room Thursday, November 16, 2006 1:30 P.M. 1. CALL TO ORDER 2. APPROVAL OF MINUTES OF OCTOBER 20, 2006 3. CORRESPONDENCE Memo regarding Ray Barilleau's term expiration and election requirement 4. MONTHLY STATEMENT TO OCTOBER 31, 2006 5. MONTHLY BILLS AND PENSION PAYMENTS 6. UNFINISHED BUSINESS 7. NEW BUSINESS 8. ADJOURNMENT N.✓ .pro MINUTES FIREMEN'S PENSION BOARD CITY OF RENTON October 20, 2006 Kathy Keolker, Mayor Don Persson, Council Finance Committee Chair Bonnie Walton, City Clerk Ray Barilleaux, Fire Department Representative Bruce Phillips, Fire Department Representative William Larson, Fire Department Alternate The rescheduled regular meeting of the Firemen's Pension Board was called to order by Acting Chairman Don Persson at 1:34 p.m. in the Mayor's conference room, 7th floor of Renton City Hall. In attendance were Board members Don Persson, Ray Barilleaux, Bruce Phillips and Bonnie Walton. Also in attendance was Finance Department representative, Jill Masunaga. MINUTES APPROVAL MOVED BY BARILLEAUX, SECONDED BY PHILLIPS, THE PENSION BOARD APPROVE THE MINUTES OF THE SEPTEMBER 21, 2006, MEETING. CARRIED. MONTHLY STATEMENT The financial report as of September 30, 2006, was reviewed. Total cash/investment balance was $4,578,967.06. MONTHLY BILLS AND PENSION PAYMENTS MOVED BY PHILLIPS, SECONDED BY BARILLEAUX, THE BOARD APPROVE THE PENSION/MEDICAL PAYMENTS FOR OCTOBER 2006, IN THE TOTAL AMOUNT OF $33,882.94 TO BE PAID FROM THE FIREMEN'S PENSION FUND. CARRIED. ADJOURNMENT MOVED BY BARILLEAUX, SECONDED BY PHILLIPS, THE MEETING OF THE FIREMEN'S PENSION BOARD BE ADJOURNED. CARRIED. Time: 1:37 p.m. 131424.4V - Bonnie I. Walton, City Clerk Member and Secretary, Firemen's Pension Board o��Y oADMINISTRATIVE, JUDICIAL, AND fs ' LEGAL SERVICES DEPARTMENT ,eP Is Office of the City Clerk MEMORANDUM DATE: November 9, 2006 TO: I. David Daniels, Fire Chief FROM: V7 Bonnie Walton, City Clerk and Firemen's Pension Board member/Secretary,x6502 SUBJECT: Firemen's Pension Board Term Expiration The two-year term of office for Ray Barilleaux as a member of the Firemen's Pension Board expires on December 31, 2006. An election among the firefighters must be held so that the position may be filled accordingly. Retired members are eligible both to elect and be elected to serve on the board. Following the election,please report the name of the firefighter elected to serve on the board for a two-year term from January 1, 2007 to December 31, 2008. Thank you for your assistance. I can be reached at x6502 if you need additional information. cc: Larry Rude, Deputy Fire Chief Firemen's Pension Board Members CITY OF RENTON - FIREMEN'S PENSION FUND CASH & INVESTMENT ACTIVITY REPORT AS OF OCTOBER 31, 2006 Fireman's Pension Fund Comparison of Cash and Investment Activity 6 112006 162005 5 c4 i 0 4 —Iiii • I ___ I � 0 6 N ° 3 i 2 1 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec CURRENT 2006 2006 LAST YEAR 2005 2005 ACTIVITY: MONTH YTD ADJ BUDGET CURR MO ACTUAL ADJ BUDGET BEGINNING CASH/INV BALANCE $4,578,967.06 $4,811,901.62 $4,713,823 $4,741,372.31 $4,976,122.73 $4,976,123 RECEIPTS: Fire Insurance Premium Tax 0.00 77,820.55 $73,000 0.00 72,403.73 $60,000 Investment Interest 2,153.84 19,687.03 $150,000 1,050.59 179,951.70 $100,000 DISBURSEMENTS: Fire Pension 33,669.09 346,943.24 $450,000 33,012.44 402,201.54 $410,000 Fire Pension Medical 213.85 9,736.76 $20,000 0.00 0.00 $0 Office/Operating Supplies 0.00 316.24 $400 0.00 400.00 $400 Actuarial/Firemen's Pens 0.00 0.00 $0 0.00 7,075.00 $5,000 Reimb General/Clerical&Acct 575.00 5,750.00 $6,900 575.00 6,900.00 $6,900 ENDING CASH/INV BALANCE $4,546,662.96 $4,546,662.96 $4,459,523 $4,708,835.46 $4,811,901.62 $4,713,823 CURRENT PREVIOUS LAST YEAR LAST YEAR ACTIVITY: MONTH MONTH CURR MO PREV MO CASH $121,862.13 $154,166.23 $57,461.37 $89,998.22 INVESTMENTS: CD's&State Investment Pool 454,767.46 454,767.46 454,767.46 454,767.46 Federal National Mortgage Assn 99,555.84 99,555.84 99,555.84 99,555.84 Treasury Strips&Zero Coupon Bonds 3,870,477.53 3,870,477.53 4,097,050.79 4,097,050.79 TOTAL CASH AND INVESTMENTS $4,546,662.96 $4,578,967.06 $4,708,835.46 $4,741,372.31 The State Investment Pool interest 5.1931% 5.2023% 3.7576% 3.5788% H:\FINANCE\FINPLAN\FIREPEN\1_Fire_Pension_2006.xls\Oct06 Page 1 11/9/2006 Now *art FIREMEN'S PENSION BOARD PENSION/MEDICAL PAYMENTS FOR NOVEMBER, 2006 Recipient Pension Amt Medicals Total . ANKENY, Charlie (Captain) $139.24 139.24 ASHURST, James (Assistant Chief) $4,166.00 754.05 4,920.05 BANASKY, George (Captain) $1,097.46 1,097.46 BARILLEAUX, Ray (Battalion Chief) - - BEATTEAY, Karlen (Widow) $220.15 220.15 BERGMAN, Claudette (Widow) $150.99 150.99 CHRISTENSON, Chuck (Firefighter) $309.99 309.99 CONNELL, Robert(Captain) $685.35 685.35 GEISSLER, Dick (Fire Chief) - - GOODWIN, Charles (Captain) $3,780.00 627.52 4,407.52 GOODWIN, Donald (Firefighter) $923.38 923.38 HAWORTH, Constance (Widow) $2,592.09 2,592.09 HAWORTH, Jack (Firefighter) $2,851.50 - 2,851.50 HENRY, William, Jr. (Captain) $1,213.48 1,213.48 HURST, Gerald (Firefighter) $589.23 589.23 JONES, Evelyn M. (Widow) $237.45 237.45 LARSON, William (Firefighter) - - LAVALLEY, Theodele (Captain) $339.47 339.47 MATTHEW, James (Deputy Chief) - - MC LAUGHLIN, JACK(Battalion Chief) $753.28 753.28 NEWTON, Gary (Lieutenant) $259.52 259.52 NEWTON, Roger(Firefighter) - - NICHOLS, Gerald (Battalion Chief) $357.33 357.33 PARKS-ANDREASON,Arlene (Widow) $315.41 315.41 PARKS, John (Firefighter) $2,959.50 250.01 3,209.51 PHILLIPS, Bruce H. (Deputy Chief) $85.47 85.47 PRINGLE,Arthur(Captain) $446.68 446.68 PRINGLE, S. Joan (Widow) $2,226.91 2,226.91 RIGGLE, David E. (Firefighter D Step) $87.82 87.82 RUPPRECHT, Jim (Firefighter D Step) $118.88 118.88 SMITH, Leroy(Firefighter) $378.37 378.37 STROM, Karl (Firefighter) $2,851.50 - 2,851.50 TODD, Franklin (Firefighter) $431.58 431.58 TONDA, Lila Jean (Widow) $30.07 30.07 VACCA, Nick (Lieutenant) $292.90 292.90 WALLS, Kenneth (Firefighter D Step) $144.12 144.12 WALLS, Mercedes (Widow) - - WALSH, David (Firefighter) $964.81 964.81 WALSH, Patrick(Captain) $893.60 893.60 WEISS, Larry (Battalion Chief) $549.39 549.39 WILLIAMS, Alta (Widow) - - WOOTEN, Marilyn E. (Widow) $226.17 226.17 .Totall‘Expenses: PenslonlMedtcatf, Prior Year Pension/Medical Payments: Total Pension Payments for November, 2005 33,512.44 Total Medical Bills Reimbursed in November, 2005 1,918.11 Total Expenses: Medical/Pension 35,430.55 4_SUMMARY 2006.XLS 11/9/2006 V Nero FIREMEN'S PENSION BOARD MEDICAL BILLS TO BE REIMBURSED IN NOVEMBER, 2006 PAYMENT Page ` •Name Pharmacy/MedicaFFacility ; Amount of Bill 2 James Ashurst Safeway 6.75 2 James Ashurst Safeway 179.45 2 James Ashurst Safeway 7.75 2 James Ashurst Safeway 7.75 2 James Ashurst Safeway 179.45 2 James Ashurst Safeway 83.79 3 James Ashurst Safeway 107.25 3 James Ashurst Safeway 175.11 3 James Ashurst Safeway 6.75 James Ashurst 754.05 5 Charles Goodwin Bartell Drugs 6.35 5 Charles Goodwin Bartell Drugs 131.95 5 Charles Goodwin Bartell Drugs 72.51 5 Charles Goodwin Bartell Drugs 6.35 6 Charles Goodwin Bartell Drugs 131.95 6 Charles Goodwin Bartell Drugs 278.41 Charles Goodwin 627.52 Jack Haworth 0.00 8 John Parks Olympic Drug 5.00 8 John Parks Olympic Drug 26.22 8 John Parks Olympic Drug 5.00 8 John Parks Olympic Drug 153.67 8 John Parks Olympic Drug 60.12 John Parks 250.01 Karl Strom 0.00 -:A TALI Y§ .. ., A' " ::3.� r =:..;.• .. #• ,. .. y'akj .. '• ? �;; x 3'`J.l i/�l . Si 3_2006 FP Medical.XLS 11/9/2006 • SEND CLAIM TO: ver City of Renton r'inance Dept.-Fire Pension 1055 South Grady Way Renton, WA 98055 01�Y 0 CITY OF RENTON FIREMEN'S PENSION BOARD Pharmacy/Medical Claim Reimbursement Request 1) DATE C 2) DISABILITY RETIREE'S NAME(print) < �'ftd�-�T 3) ADDRESS 23 /(2, ' fit/ ; (J , Fejt/Li t;�� -- q 7 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 7-D 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 all claims submitted are related to my disability as determined at the time of my retirement fro' the Renton Fire Department. Signature: Note: Supporting documentation must be attached. SAFEWAY PHARMACYtf6SE'UTR IDP 1A IACY is) 200 SOUTH 3RD STREET RENTON,WA 98055 RENTON,WA 98055 #1 63 (425)226-0325 #1563 (425)226-0325 Official Receipt-Please retain for tax or insurance Official Receipt Please retain for tax or insurance ASHURST,JAMES (425)255-6154 ASHURST,JAMES (425)255-6154 223 B GARDEN AVE N. 12/17 223 B GARDEN AVE N. 12/17 RENTON,WA 98055 RENTON, WA 98055 DR. GRAVES,DANIEL [RF] DR. GRAVES,DANIEL [RF] 17900 TALBOT RD S 17900 TALBOT RD S RENTON,WA 98055 RENTON,WA 98055 Rx:6676536 Jul 31, 2006 Safety Cap: Yes Rx:6673803 Oct 24, 2006 Safety Cap: Yes METOPROLOL 50MG TAB (URL ) Qty: 100 TAB FUROSEMIDE IX 40MG 40MG TABTAB A(SAND)Qty: 100 TAB Ge HSGI Ref:A1066975846961 NDC:00781.1966.10 HSGIMRT Ref:A4066121105941 NDC:00677.1482.10 REGENCE BLUESHIELD WASHINGTN REGENCE BLUESHIELD WASHINGTN Amount Due: $7.75 Amount Due: $6.75 • Oil Jill IIIII1HIIIIII IIIIJJJ1 J JREFL YOURPRESCR'"•inue DII II IUlfllH II go t`("Rx"tel REFILL SYOUR PRESCRIPTIONS 31 SAFEWAY0 SUSTREET PHARMACY AttER ITH ACY IS/ RENTON,WA 98055 RENTON,WA 98055 #1563 (425)226-0325 #1563 (425)226-0325 Official Receipt- Please retain for tax or insurance Official Receipt-Please retain for tax or insurance ASHURST,JAMES (425)255-6154 ASHURST,JAMES (425)255-6154 223 B GARDEN AVE N. 12/17 223 B GARDEN AVE N. 12/17 RENTON,WA 98055 RENTON,WA 98055 DR. GRAVES,DANIEL [RF] DR. GRAVES,DANIEL ERF] 17900 TALBOT RD S 17900 TALBOT RD S RENTON,WA 98055 RENTON,WA 98055 Rx:6672383 Sep 05, 2006 Safety Cap: Yes Rx:6672383 Oct 24, 2006 Safety Cap: Yes PROTONIX 40MG TAB (WYET)Qty: 50 TAB PROTONIX 40MG TAB (WYET)Qty: 50 TAB Ref:40066488212361 NDC:00008.0841-81 BBAIMRN Ref:45066978498461 NDC:00008.0841.81 HSGIMRT REGENCE BLUESHIELD WASHINGTN REGENCE BLUESHIELD WASHINGTN Amount Due: $179.45 Amount Due: $179.45 Hill!11111 I I I I I II III II IR.SREFILL YOUR SAffWAYCOM PRESCRIPTIONS ORIM111111111111111 'Rx I REFILL YOUR SAFEWAY.COM PRESCRIPTIONS 4 w (81 SAFEWAY PHARMACY SAFEWAY PHARMACY 200 SOUTH 3RD STREET 200 SOUTH 3RD STREET RENTON,WA 98055 (Si RENTON,WA 98055 #1563 (425)226-0325 #1563 (425)226-0325 Official Receipt - Please retain for tax or insurance Official Receipt-Please retain for tax or insurance ASHURST,JAMES (425)255-6154 ASHURST,JAMES (425)255-6154 223 B GARDEN AVE N. 12/17 223 B GARDEN AVE N. 12/17 RENTON,WA 98055 RENTON,WA 98055 DR. GRAVES,DANIEL [RF] DR. GRAVES,DANIEL [RF] 17900 TALBOT RD S 17900 TALBOT RD S RENTON,WA 98055 RENTON,WA 98055 Rx:6673803 Sep 05, 2006 Safety Cap: Yes Rx:6672388 Oct 24, 2006 Safety Cap: es FUROSEMIDE 40MG TAB (SAND)Qty: 100 TAB COZAAR 50MG TAB (MERC)Qty: TAB Generic for:LASIX 40MG TAB A Ref:45066480689821 NDC:00781-1966-10 BBAIMRN Ref:43066975845651 NDC:00006-0952-54 / HSG!MRT REGENCE BLUESHIELD WASHINGTN REGENCE BLUESHIELD WASHINGTN Amount Due: $7.75 Amount Due: $83.79 IIIIIIIIIIIIJIIIII""l'II'I i Rx REFILL SAffWAYCOMPRESCRIPTIONS 1111 11 11 11111011111 10111111'I I I £ YuimPlIESCRISAFEWAYCOM PTIONS Nese Nuri csi SAFEWAY PHARMACY 200 SOUTH 3RD STREET RENTON,WA 98055 #1563 (425)226-0325 Official Receipt- Please retain for tax or insurance ASHURST,JAMES (425)255-6154 223 B GARDEN AVE N. 12/17 RENTON,WA 98055 DR. GRAVES,DANIEL [RF] 17900 TALBOT RD S RENTON,WA 98055 Rx:6671684 Oct 24, 2006 Safety Cap: Yes CLOPIDOGREL 75MG TAB (APOT)Qty: 30 TAB Ref:A3066973301741 NDC:60505-0253-01 HSGIMRT REGENCE BLUESHIELD WASHINGTN Amount Due: $107.25 II II II II II II IIIIII I I I I I II III II R. REFILL YOUR SAfEWAY.COM PRESCRIPTIONS (51 Fu fsim "--CY RENTON,WA 98055 # (425)226-0325 Official Receipt-Please retain for tax or insurance ASHURST,JAMES (425)255-6154 223 B GARDEN AVE N. 12/17 RENTON,WA 98055 DR. GRAVES,DANIEL [NW] 17900 TALBOT RD S RENTON,WA 98055 Rx:6684872 Oct 25, 2006 Safety Cap: Yes LIPITOR 40MG TAB (PFIZ) Qty: 50 TAB Ref:A4066988070321 NDC:00071-0157-23 BBAIMRN REGENCE BLUESHIELD WASHINGTN Amount Due: $175.11 II II II II II II IIIIII I I I I I II III II REFILL j SAfEWAY.COM PRESCRIPTIONS • (53) ANL 3 SI ACY RENTON,WA 98055 # (425)226-0325 Official Receipt- Please retain for tax or insurance (425)255-6154 23 B GARDEN AVE N. 12/17 RENTON,WA 98055 DR. GRAVES,DANIEL [NW] 17900 TALBOT RD S RENTON,WA 98055 Rx:6684874 Oct 25, 2006 Safety Cap: Yes METOPROLOL 50MG TAB (URL ) Qty: 100 TAB Generic for:METOPROLOL 50MG TAB Ref:A7066983092711 NDC:00677-1482-10 BBAI REGENCE BLUESHIELD WASHINGTN Amount Due: $6.75 TpA 3 ``"'° SEND CLAIM TO: ""1" City of Renton Finance Dept.-Fire Pension 1055 South Grady Way Renton, WA 98055 CITY OF RENTON FIREMEN'S PENSION BOARD Pharmacy/Medical Claim Reimbursement Request 1) DATE 2) DISABILITY RETIREE'S NAME (print) C f f1 U%� /} . "U O2)cd/ ) 3) ADDRESS I l l y Al 01U k.O £ 1i 02 R ,V t WSZ. 4) DISABILITY AT TIME OF RETIREMENT 1ieI f ('CIU1. I f/O/ti `a'`I /) errektsiov c 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.) tY 6) TOTAL AMOUNT OF CLAIlVI 3_ 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: Ut-r-64-v 11,14A �� -� Note: Supporting documentation must be attached. 12 ;Ito& ,44,..# No_ ge-ze.4 ".____, `—r® pe--AL , 6 , :- 616 II---, aitb)(\ b7-(A--G /- , 600b(-01 4) - fl-e--"A"--ej--'c- FPA ill : CA-FAe-t- C - 1:3:1:b00Aq DRUGS BARTELL DRUGS s--Washington's Own Dragstonaransam Wa.hisesow'sOwn orugstor.. RX# 45-297800 E DR. FLO RX# 45- 310592 E DR. LORCH,GERALD ° DATE: 09/29/06 R (425)251-5110 TATE: 09/29/06 R (425)251-5110 NAME: CHARLES GOODWIN NAME: Hak ES GOODWIN 1414 MONROE AVE NE#306 141 ONROE VE NE#306 GEMFOZIL 600MG TABLET(*AP LOPURINO 100MG TABLET(MYL 60505-06N-04 22150086 0 378 137-01 22218086 REFILL 1 QUANTITY 180.00 REFILL YES QUANTITY 30.00 BARTELL DRUGS PRICE= $91.78 BARTELL DRUGS PRICE= $10.99 WITH XPS THE AMOUNT DUE:$72.51 WITH XPS THE AMOUNT DUE:$6.35 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 APPRECIATE YOUR BUSINESS.TO PROVIDE YOU WE TRULY APPRECIATE YOUR BUSINESS.TO PROVIDE YOU WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR L REFILLS 24 46 HOURS IN ADVANCE REFILLS 24-48 HOURS IN ADVANCE I BARTELL DRUGS I BARTELL DRUGS w>< s°n' Rx# o dE D ,GERALD Px# 45- 339s E DR'rugG . RIFFITH,ALIDA 45-3105 2 E DR. LORCH DATE: 09/29/06 N (425)899-3123 DATE: 10/08/06 R (425)251-5110 NAME: CHARLES GOODWIN . NAME: CHARLES GOODWIN 1414 MONROE AVE NE#306 1414 MONROE AVE NE#306 4GGROX AP 200/25 ALLO OL 100MG TABLET(MYL 00597-00 1-60 22967885 00378-01 -01 23326667 REFILL 4 QUANTITY 60.00 REFILL YES QUANTITY 30.00 BARTELL DRUGS PRICE= $172.99 BARTELL DRUGS PRICE= $10.99 WITH XPS THE AMOUNT DUE=$131.95 WITH XPS THE AMOUNT DUE:$6.35 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 APPRECIATE YOUR BUSINESS. TO PROVIDE YOU WE TRULY APPRECIATE YOUR BUSINESS. TO PROVIDE YOU WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR REFILLS 24-48 HOURS IN ADVANCE L REFILLS 24-48 HOURS IN ADVANCE L ..-- t? • 6 pezi,teuoyv aitv, a.-4,00eri //), 4T)70 . (- --66.bt-th --- )Ilit\ BARTELL DRUGS RX# tif On a E DR ngGRIFF�;ALIDA DATE: 10/27/06 R (425)899-3123 NAME: CHARLES GOODWIN 1414 MONROE AVE NE#306 AGGR NO AP 200/25 00597-Or01-60 25253878 BARTELL DRUGS ••••••••••-.—Washington's Own Drugstores+�s��, REFILL 3 QUANTITY 60.00 RX# 45-290322 E DR. GRIFFITH,ALIDA BARTELL DRUGS PRICE_.$172.99 DATE: 10/27/06 R (425)899-3123 WITH XPS THE AMOUNT DUE= 131.95 NAME: CHARLES GOODWIN 1414 MONROE AVE NE#306 BARTELL DRUGS#45 CARBIDOPA/LEVODOPA 25MG/100M (425)793-1015 00093-0293-01 4700 NE 4TH STREET 25728878 RENTON,WA 98059 ,A REFILL 2 QUANTITY 00 THANK YOU BARTELL DRUGS PRICE= $388.99 WE TRULYHAPPRECIATE YOUR BUSINESS.PLE TO PROVIDE YOU WITH XPS THE AMOUNT DUE= 278.41 WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR REFILLS 24-48 HOURS IN ADVANCE BARTELL DRUGS#45 (425)793-1015 4700 NE 4TH STREET RENTON,WA 98059 THANK YOU WE TRULY APPRECIATE YOUR BUSINESS. TO PROVIDE YOU WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR •L REFILLS 24-48 HOURS IN ADVANCE --rtf-4,1Lo &12-- "3 QLp bO� . SEND CLAIM TO, City of Renton Ise 'wrr'Finance Dept.-Fire Pension 1055 South Grady Way Renton, WA 98055 Oti�Y 0 4 + �'N'f0� CITY OF RENTON FIREMEN'S PENSION BOARD Pharmacy/Medical Claim Reimbursement Request 1) DATE 0(� 2) DISABILITY RETIREE'S NAME (print) \i 0 Ii'11 lei 1,. P r q 3) ADDRESS 335 3 Ave f769 4671, v i e w W4, l fl b3 ot 1 4) DISABIL TY AT TIME OF RETI MENT ''it �a g ti S e H 1 a1'.L. le�riiaft ei 4 A-'n)cr ,rob € t Y 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.) M eA l rrif �a� 61-78- 34tOtit art A WX t 'y Hca lo (moi s 6) TOTAL AMOUNT OF CLAIM 3 O ' � r 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 all claims submitted are related to my disability as determined at the time of my irement from the Renton Fire Department. Signature: } ;,'}Z_ Note: Supporting documentation must be attached. 'Reg V fir✓ `44001 Value also smilin RECEIPT YNPIC DRUG SAVE FOR INSURANCE 1244 15thkg,�}ouurnw,WA 98632 Ph.(360)423-3360 OR TAX RECORDS Rx# .�tiJJ For. JOHN PARKS 10.04.06 CRN:88066772971331 1335 3RD AVE#109 LONGVIEW,WA 98632 13601 577.6684 LACTULOSE SOL 10G115ML #946 NDC: 60432-0037-32 OR. RICHARDS,JOHN E ZAS COPAY: $5.00 IIlIIIHIIIIIIHiIIIlIIIIIHIIIIIIHIIlIprce I Imo Value et the smiling'O' pK�VQ RECEIPT SAVE FOR INSURANCE 124415thAvv.41tyjn WA 98632 Ph.(360)423-3360 OR TAX RECORDS Rx# [L,'�J For: JOHN PARKS 10-04-06 1335 3RD AVE#109 LONGVIEW,WA 98632 1360) 577-6684 ALPRAZOLAM 0.5MG TAB #120 NDC:R. RICHARDS,JOHNE1-1077-05 $26.22 111111111111111111111111111111111 I I I 111 Price J Value.t the smiling'0' YMPIC DRUG RECEIPT 1244 15thAvv..LonavigwOR TAX RECORDS ,WA 98632 Ph.(360)423-3360 SAVEFOR INSURANCE 1574, O 11x# For: JOHN PARKS 10-04-06 CRN:82068772910121 1335 3RD AVE#109 LONGVIEW,WA 98632 (360) 577-6684 MIRTAZAPINE SOLTAB 45MG #30 NDC: 66993-0712-30 DR. RICHARDS,JOHN E ZAS COPAY: $5.00 II I I II liii II I I II 11111111 liII 011111111 Price J Value at the smiling'0' nr/p1�ORV6 RECEIPT SAVE FOR INSURANCE 1244 15th(pkigh WA 98632 Ph.(360)423-3360 OR TAX RECORDS 11x# For For. JOHN PARKS 10-04-06 1335 3RD AVE#109 LONGVIEW,WA 98632 (360) 577-6684 ,4MBIEN 10MG TABS#### #30 4.542t-50 RICHARDS,JOHN E DR. $153.67 II 11011 I III IIIA, II 0IIII 111111111111 IlIlPrice veluinthesmiling Don RECEIPT SAVE FOR INSURANCE 1244 15thv . w,WA 98632 Ph.(360)423-3360 OR TAX RECORDS RHa040��/Y For JOHN PARKS 10-04-06 1335 3R0 AVE#109 LONGVIEW,WA 98632 (360) 577-6684 PRILOSEC OTC 20MG TAB" #84 O045503 RICHARDS,JOHN E OR. $60.12 11111111 111111II 111111 II 11111111111 I