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Home My WebLink AboutFinal Agenda Packet vue vie CITY OF RENTON FIREMEN'S PENSION BOARD Regular Meeting 7th Floor-Mayor's Conference Room Thursday, November 20, 2008 2:00 P.M. 1. CALL TO ORDER 2. APPROVAL OF MINUTES OF OCTOBER 16, 2008 3. CORRESPONDENCE 4. MONTHLY STATEMENT TO OCTOBER 31, 2008 5. MONTHLY BILLS AND PENSION PAYMENTS 6. UNFINISHED BUSINESS 7. NEW BUSINESS 8. ADJOURNMENT 'woe vat MINUTES FIREMEN'S PENSION BOARD CITY OF RENTON October 16, 2008 Denis Law, Mayor Don Persson, 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 Chairman Denis Law at 2:04 p.m. in the Mayor's conference room, 7th floor of Renton City Hall. In attendance were Board members Denis Law, Ray Barilleaux, and Don Persson; and also Jason Seth, Deputy City Clerk and Jill Masunaga, Finance Department Representative. MINUTES APPROVAL MOVED BY PERSSON, SECONDED BY BARILLEAUX, THE PENSION BOARD APPROVE THE MINUTES OF THE SEPTEMBER 18, 2008, MEETING. CARRIED. MONTHLY STATEMENT The financial report as of September 30, 2008, was reviewed. Total cash/investment balance was $4,482,570.35. MONTHLY BILLS AND PENSION PAYMENTS MOVED BY BARILLEAUX, SECONDED BY PERSSON, THE BOARD APPROVE THE PENSION/MEDICAL PAYMENTS FOR OCTOBER 2008, IN THE TOTAL AMOUNT OF $41,597.91. CARRIED. ADJOURNMENT MOVED BY BARILLEAUX, SECONDED BY PERSSON, THE MEETING OF THE FIREMEN'S PENSION BOARD BE ADJOURNED. CARRIED. Time: 2:07 p.m. ,Wo ason A. Seth, Deputy City Clerk Acting Secretary, Firemen's Pension Board • CITY OF RENTON - FIREMEN'S PENSION FUND CASH & INVESTMENT ACTIVITY REPORT AS OF OCTOBER 31, 2008 Fireman's Pension Fund Comparison of Cash and Investment Activity 6 0 2008 ❑2007 5 - — 0 4 0 48 w o c 3 i 2 1 - Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec CURRENT 2008 2008 LAST YEAR 2007 2007 ACTIVITY: MONTH YTD ADJ BUDGET CURR MO ACTUAL ADJ BUDGET BEGINNING CASH/INV BALANCE $4,482,570.35 $4,694,232.48 $4,203,347 $4,437,462.82 $4,672,241.19 $4,459,523 RECEIPTS: Fire Insurance Premium Tax 0.00 85,949.42 75,000 0.00 85,061.56 73,000 Investment Interest 599.82 105,697.89 200,000 1,853.87 389,226.86 175,000 DISBURSEMENTS: Fire Pension 41,011.77 429,760.08 552,400 34,695.56 427,011.96 463,500 Fire Pension Medical 808.27 6,935.80 20,000 561.55 9,059.17 20,000 Office/Operating Supplies 0.00 372.78 459 0.00 450.00 450 Actuarial/Firemen's Pens 0.00 0.00 0 0.00 7,550.00 12,000 Reimb General/Clerical&Acct 829.00 8,290.00 9,948 686.00 8,226.00 8,226 ENDING CASH/INV BALANCE $4,440,521.13 $4,440,521.13 $3,895,540 $4,403,373.58 $4,694,232.48 $4,203,347 CURRENT PREVIOUS LAST YEAR LAST YEAR ACTIVITY: MONTH MONTH CURR MO PREV MO CASH $590,077.75 $632,126.97 $197,661.31 $231,750.55 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 3,206,796.27 3,206,796.27 3,651,388.97 3,651,388.97 INTEREST ACCRUED 89,323.81 89,323.81 TOTAL CASH AND INVESTMENTS $4,440,521.13 $4,482,570.35 $4,403,373.58 $4,437,462.82 The State Investment Pool interest 2.4652% 2.3892% 4.9108% 5.1232% H:\FINANCE\FINPLAN\FIREPEN\1 Fire Pension 2008.xIs\Oct08 Page 1 11/14/2008 '� FIREMEN'S PENSION BOARD " '' PENSION/MEDICAL PAYMENTS FOR NOVEMBER, 2008 `_. ;.R cipieiit,, Fenlon Amt Medicals-` . , Total ANKENY, Charlie (Captain) $90.81 90.81 ASHURST, James (Assistant Chief) $4,569.00 451.62 5,020.62 BANASKY, George (Captain) $1,502.59 1,502.59 BARILLEAUX, Ray(Battalion Chief) - - BEATTEAY, Karlen (Widow) $192.17 192.17 BERGMAN, Claudette (Widow) $118.24 118.24 CHRISTENSON, Chuck (Firefighter) $523.58 523.58 CONNELL, Robert(Captain) $678.13 678.13 GEISSLER, Dick(Fire Chief) $641.73 641.73 GOODWIN, Charles (Captain) $4,010.50 595.48 4,605.98 GOODWIN, Donald (Firefighter) $1,277.48 1,277.48 HAWORTH, Constance(Widow) $2,792.83 2,792.83 HAWORTH, Jack (Firefighter) $3,025.00 - 3,025.00 HENRY, William, Jr. (Captain) $1,805.36 1,805.36 HURST, Gerald (Firefighter) $488.91 488.91 JONES, Evelyn M. (Widow) $208.91 208.91 LARSON,William (Firefighter) $222.80 222.80 LAVALLEY, Theodele (Captain) $306.38 306.38 MATTHEW, James (Deputy Chief) $193.70 193.70 MC LAUGHLIN, JACK (Battalion Chief) $1,601.18 1,601.18 NEWTON, Gary(Lieutenant) $226.76 226.76 NICHOLS, Gerald (Battalion Chief) $467.89 467.89 PARKS-ANDREASON, Arlene(Widow) $284.16 284.16 PARKS, John (Firefighter) $3,139.50 22.60 3,162.10 PHILLIPS, Bruce H. (Deputy Chief) $909.45 909.45 PRINGLE,Arthur(Captain) $421.16 421.16 PRINGLE, S. Joan (Widow) $2,399.37 2,399.37 RIGGLE, David E. (Firefighter D Step) $49.58 49.58 RUPPRECHT, Jim (Firefighter D Step) $83.02 83.02 SMITH, Leroy(Firefighter) $363.04 363.04 STROM, Karl (Firefighter) $3,025.00 39.89 3,064.89 TODD, Franklin (Firefighter) $420.32 420.32 TONDA, Lila Jean (Widow) $531.29 531.29 VACCA, Nick (Lieutenant) $265.10 265.10 WALLS, Camille (Widow) $108.43 108.43 WALLS, Mercedes (Widow) $729.93 729.93 WALSH, David (Firefighter) $1,322.07 1,322.07 WALSH, Patrick (Captain) $902.97 902.97 WEISS, Larry(Battalion Chief) $1,354.42 1,354.42 WILLIAMS, Alta (Widow) - - WOOTEN, Marilyn E. (Widow) $200.10 200.10 0i Ti i1?F40i,0 0,400166/M4410 *'$: $.4'1;45228 t , $009,401*.44$42002145 Prior Year Pension/Medical Payments: Total Pension Payments for November, 2007 34,695.56 Total Medical Bills Reimbursed in November, 2007 784.50 Total Expenses: Medical/Pension 35,480.06 4_SUMMARY 2008.XLS 11/14/2008 sow' sow FIREMEN'S PENSION BOARD MEDICAL BILLS TO BE REIMBURSED IN NOVEMBER, 2008 PAYMENT Page` : : Nairne:r- ,'•:Pharmacy/Medical Facility Date" - Amount of Biil 2 James Ashurst Safeway 09/08/08 102.15 2 James Ashurst Safeway 09/22/08 10.99 2 James Ashurst Safeway 09/22/08 11.99 2 James Ashurst Safeway 09/22/08 141.80 2 James Ashurst Safeway 09/23/08 82.54 2 James Ashurst Safeway 10/12/08 102.15 451.62 4 Charles Goodwin Bartell Drugs 08/22/08 49.59 4 Charles Goodwin Bartell Drugs 08/22/08 12.14 4 Charles Goodwin Bartell Drugs 08/22/08 10.99 4 Charles Goodwin Bartell Drugs 08/23/08 182.27 5 Charles Goodwin Bartell Drugs 09/12/08 84.44 5 Charles Goodwin Bartell Drugs 09/27/08 49.59 5 Charles Goodwin Bartell Drugs 09/22/08 182.27 5 Charles Goodwin Bartell Drugs 09/29/08 9.89 6 Charles Goodwin Safeway 10/13/08 14.30 595.48 Jack Haworth 0.00 8 John Parks Olympic Drug 10/03/08 14.01 8 John Parks Olympic Drug 10/03/08 2.31 8 John Parks Olympic Drug 10/03/08 6.28 22.60 10 Karl Strom Sam's Club 10/03/08 4.00 10 Karl Strom Sam's Club 10/03/08 3.00 10 Karl Strom Sam's Club 10/03/08 7.00 11 Karl Strom Sam's Club 10/03/08 4.41 11 Karl Strom Sam's Club 10/03/08 9.00 11 Karl Strom Sam's Club 10/20/08 12.48 39.89 ,':'4.!,,' ) 'tlITOTAI, " .., +_.': *.,', ;MrS"': 1 gip:'- .. ' zr ';:i1;1:09:59: 3_2008 FP Medical XLS Page 1 of 1 11/14/2008 `ow' SENDCLAIMTO: City of Renton Finance Dept.-Fire Pension 1055 South Grady Way Renton, WA 98057 1`rz O 0 A CITY OF RENTON FIREMEN'S PENSION BOARD Pharmacy/Medical Claim Reimbursement Request 1) DATE OctoJ,er 15 2008 2) DISABILITY RETIREE'S NAME (print) James F. Ashurst A 3) ADDRESS 223 Larsen Ave.N. #B Renton Wa. 98057 9 4) DISABILITY AT TIME OF RETIREMENT Hypertension H.B.P. 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 retirement disability,provided that the expense is not covered by another plan,source or insurance coverage. Supporting documentation for all must be attached.) Medi rai-i on fnr HypPri-Pnsi nn 6) TOTAL AMOUNT OF CLAIM: $ $451 . 62 Amount of total claim (above) that is related to the Retirement Disability: $ 369. 08 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: ,,/' ,,e,J Ct 1 U Note: Supporting documentation must be attached. 18) • 200SAFSEWA UTH R RREERMT ACXv��Dp ACY RENTON,WA 98055 RENTON,WA 98055 #1563 (425)226-0325 ACV (425)226-0325 ,Official Receipt- Please retain for tax or insurance Official lieceipt-r lease retain tor 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, STE 101 17900 TALBOT RD S,STE 101 RENTON,WA 98055 AskAF RENTON,WA 98055 AskAF Rx:6710376 Sep 08, 2008 Safety Cap: Yes Rx:6702058 Sep 22, 2008 Safety Cap: Yes PANTOPRAZOLE 40MG TAB (PRAS)Qty: 30 TAB PLAVIX 75MG TAB (B-M ) Qty: 30 TAB Generic for:PROTONIX 40MG TAB Ref:A0086522421431 NDC:00008.0607.01 BBAISDP Ref:A2086663762531 NDC:63653.1171.06 HSGITC1 REGENCE BLUESHIELD WASH Cash Price: 134.49 REGENCE BLUESHIELD WASH Cash Price: 194.99 Amount Due: $102.15 Amount Due: $141.80 II II II II II II 111111 I I I I I II III II SREFILL YOUR SAFEWAY.COM TIONS 0111111111 I 111111111 EFS YOUR 54FEWAY.COM PRESCRIPTIONS Aignithi 1DACY NNyDPmMACY RENTON,WA 98055 3 RENTON,WA 98055 Ltictai (425)226-0325 ## (425)226-0325 Seceirit- Fiease retain tor tax or insurance • - -I• - ' •• . - • • • . • • : 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,STE 101 17900 TALBOT RD S,STE 101 RENTON,WA 98055 AskAF RENTON,WA 98055 AskAF Rx:6701702 Sep 22, 2008 Safety Cap: Yes Rx:6706816 Sep 23, 2008 Safety Cap: Yes METOPROLOL 50MG TAB (TEVA)Qty: 100 TAB HUMULIN N VIA (LILL) Qty: 20 ML Ref:A1086668643481 NBC:00093-0733-10 HSGITC1 Ref:A9086678713821 NDC:00002-8315-01 HSGIPSH REGENCE BLUESHIELD WASH Cash Price: 10.99 REGENCE BLUESHIELD WASH Cash Price: 89.98 Amount Due: $10.99 Amount Due: $82.54 HI 1 I O 111111111111111 Rx REFILL YOUR PRESCRIPTIONS IUIIllIl IIIIIIIIIIIIIIIIIIIIIIIIIIIIIRx EfILL YOUR @SAFEWAy�PRESCRIPTIONS - • - , -VERY DAY , -ur t7 UNI - z IWIINf ACY §NVIRFINALMAcY RENTON,WA 98055 RENTON,WA 98055 #CV (425)226-0325 /15) (425)226-0325 Otficiar Keceipt- 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, STE 101 17900 TALBOT RD S, STE 101 RENTON,WA 98055 AskAF RENTON,WA 98055 AskAF Rx:6707635 Sep 22, 2008 Safety Cap: Yes Rx:6710376 Oct 12, 2008 Safety Cap: Yes FUROSEMIDE 40MG TAB (WATS)Qty: 100 TAB PANTOPRAZOLE 40MG TAB (PRAS) Qty: 30 TAB Generic for:FUROSEMIDE 40MG TAB Generic for:PROTONIX 40MG TAB Ref:A7086666980741 NDC:00591.0301.10 HSGITC1 Ref:A8086861817871 NBC:00008-0607-01 HSGI REGENCE BLUESHIELD WASH Cash Price: 11.99 REGENCE BLUESHIELD WASH Cash Price: 134.49 Amount Due: $11.99 Amount Due: $102.15 HIIIIIIIIIIIIIIIIIIIIIIIIIIII Rx off@SAfEWAYCOM�° IIMMINIIIIIIIIIIRx ffgISYOUR AfEWAYC MT/OAS 00000068710 TAKE r •-- -.--- • '''TH TWIT- -- - - nAl'' Piz `tar, SEND CLAIM TO: '— City of Renton Finance Dept.-Fire Pension 1055 South Grady Way Renton,WA 98057 S�Y 0 A Y" + m �NT°� CITY OF RENTON FIREMEN'S PENSION BOARD Pharmacy/Medical Claim Reimbursement Request 1) DATE / 00 Si 2) DISABILITY RETIREE'S NAME (print) C// s /11- '.00/.)Cd( iV 3) ADDRESS / /1-i /NA)g(JCU /VG � itlTO�/ ((/ �G�'6S� 4) DISABILITY AT TIME OF RETIREMENT94ka- / /� / yL r / / 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 retirement disability,provided that the expense is not covered by another pl a source or insurance coverage. Supporting documentation for all must be attached.) N,4// 6) TOTAL AMOUNT OF CLAIM: $ Amount of total claim (above) that is related to the Retirement Disability: $ /• �4 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: j' - / Note: Supporting documentation must be attached. Pk& . /D/�/Dt 7 ' : I , 4A /i ,& 1 ' ZA Act. no : 11/1-4. L .c,s ,it . c,--06DL,)„u- pd-vr-ia-H I BARTELL DRUGS I BARTELL DRUGS Woshington'r Own Drugstores�.i�. ��Washington'r Own Drugstores RX# 45-444249 E DR. KATO,GARY H. Rx# 45-448753 E DR. LORCH,GERALD DATE: 08/22/08 R (425)255-9310 DATE: 08/22/08 N (425)251-5110 NAME: CHARLES GOODWIN NAME: CHARLES GOODWIN 1414 MONROE AVE NE#306 1414 MONROE AVE NE#306 AMLODIPINE 5MG TABLET(*LUP) ALLOPURINOL 100MG TABLET(*PA 68180-0751-09 1535657459809 49884-0602-10 2137184844659 REFILL 5 QUANTITY 30.00 REFILL NO QUANTITY 30,00 BARTELL DRUGS PRICE= $54.49 �j BARTELL DRUGS PRICE= $10.99 ' ,v i WITH SR THE AMOUNT DUE-$49.59 ' 1 U• f 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 i REFILLS 24-48 HOURS IN ADVANCE L REFILLS 24-48 HOURS IN ADVANCE BARTELL DRUGS IBARTELL DRUGStrmtmtWwhington's Own Drugstores nwt•sst RX- -Washington',Own Drugstores,�_ # 45-433333 E DR. GRIFFITH,ALIDA mi 45- 406696 E DR. FLO, GAYLE DATE: 08/23/08 R (425) 899-3123 DATE: 08/22/08 R (425)251-5110 NAME: CHARLES GOODWIN NAME: CHARLES GOODWIN 1414 MONROE AVE NE#306 1414 MONROE AVE NE#306 AGGRENOX CAP 200/25 ATENOLOL 50MG TABLET(*TEVA) 00597-0001-60 1492304468709 00093-0752-10 1535654479809 REFILL 1 QUANTITY 60.00 REFILL 4 QUANTITY 30.00 a a1 �� BARTELL DRUGS PRICE= $195.99 BARTELL DRUGS PRICE= $13.49 WITH SR THE AMOUNT DUE 4182.27 WITH SR THE AMOUNT DUE-$12.14 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 RVICE POSSIBLE PLEASE WE TRULY APPRECIATE YOUR BUSINESS. TO PROVIDE YOU WITH THE BEST REFILLS 24-48 HOURS IN ADVANCE ORDER YOUR WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR L REFILLS 24-48 HOURS IN ADVANCE p • )/7 c), //,0 • bajA jzAe, (0e,• 1)4-14 Nieur Niro A - ôO BARTELL DRUGS ! BARTELL D • GS �.�N '�Ow* afond� ��Ao�hinyton',Own Drugstorri�� RX# 45-45200 E DR. FLO, GAYLE Rx* 45-433333 E DR. GRIFFITH,ALIDA DATE: 09/12/08 N (425)251-5110 DATE: 09/22/08 R (425) 899-3123 NAME: CHARLES GOODWIN NAME: CHARLES GOODWIN 1414 MONROE AVE NE#306 1414 MONROE AVE NE#306 GEMFIBROZIL 600MG TABLET(*TE AGGRENOX CAP 200/25 00093-067aQ&, 1669477897609 00597-0001-60 2459725334659 REFILL 3 QUANTITY 180.00 REFILL NO QUANTITY 60,00 BARTELL DRUGS PRICE= $91.78 BARTELL DRUGS PRICE= $195.99 pp WITH SR THE AMOUNT DUE$84.44 WITH SR THE AMOUNT DUE:$182.27 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 BARTELL DRUGS BART L DRUGS ww��t�e+hi '�Own D..rbsn,�. RX# 45- 4442 E DR. KATO,GARY H. " 45-45 E DR. LORCH,GERALD . DATE: 09/27/08 R (425)255-9310 DATE: 09/29/08 N (425)251-5110 NAME: CHARLES GOODWIN NAME: CHARLES GOODWIN 1414 MONROE AVE NE#306 1414 MONROE AVE NE#306 ALLOPURINOL 100MG TABLET(*PA AMLODIPINE 5MG TABLET(*LUP) 49884-0602-10 1963069409809 68180-0751-09 1806257498709 REFILL 4 QUANTITY 30.00 REFILL 5 QUANTITY 30.00 BARTELL DRUGS PRICE= $54.49 BARTELL DRUGS PRICE= $10.99 WITH SR THE AMOUNT DUE 449.59 ,_(C S� WITH SR THE AMOUNT DUE 49.89 9. 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 .paerS / 4/0�,f J1 j�. ,_,,,,,te__46A's - �,. qmi : (i-f LL- c x ,6-,,D4),,/-4s.P tin utiSAFEWAY PHARMACY 4300 NE 4TH STREET RENTON,WA 98059 S &FE% 4y#1468 (425)235-6251 Official Receipt - Please retain for tax or insurance TM NOBODY DOES IT BETTER FOR LESS GOODWIN,CHARLES (425)255-7782 YOUR FRIENDLY RENTON SAFEWAY 1414 MONROE AVE NE #306 06/15 RENTON,WA 98056 DR. HAYNIE,JAY [NW] 4033 TALBOT RD SSUITE 520 PHARMACY RENTON, WA 98055 Rx:6702200 Oct 13, 2008 Safety Cap: No AsRX NON-TAX ITEM PREDNISOLONE AC 1% SUS (FALC) Qty: 5 ML **** TAX 14.30 Generic for:PRED FORTE 1%OP SUS N00 $RL 1 4.30 Ref:30000145587401 NDC:61314.0637.05 PNNILP .� CASH 20,30 RESTAT FREE DRUG CARD U Cash Price: 22.99 f NANfF Amount Due: $14.30 6•00 10/13/ TEMS = 1 11111111 IIIIIIIIJ III! i� 0043 6473 I 1111111 �Rx REFILL YOUR PRESCRIPTIONS ' 29002101430 �® @ SAfEWAY.COM 1-7Irj "IL' /)144 Mr/4 F ''w'"' SEND CLAIM TO: 11161 City of Renton Finance Dept.-Fire Pension 1055 South Grady Way Renton, WA 98057 ��NTo� CITY OF RENTON FIREMEN'S PENSION BOARD Pharmacy/Medical Claim Reimbursement Request 1) DATE A/© V ?, 2D© 5 2) DISABILITY RETIREE'S NAME (print) U d f, b, Pay-kaS 3) ADDRESS / 3 t35 Ave_ l O ( 407113 vi-t4v W . 1,9632._ 4) DISABILITY AT TIME OF RETIREMENT 5' 'o a Gk ea`-(/1[ b`,s,-a‘-e lit e e rs) J( i i"a i_. n e-r n a- and. 4 n X'i -e$y F7.--rob) --)ns 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 retirement disability,provided that the expense is not covered by another plan,source or insurance coverage. Supporting documentation for all must be attached.) p'1 ed 1 e._!--n e -c'd r aci rn e) A_ 311.4 A vi xpert, P�*b k9li s 6) TOTAL AMOUNT OF CLAIM: $ 2 , Amount of total claim(above) that is related to the Retirement Disability: $ . r 6 0 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: e / i YeA7/444/ Note: Sup.eV ing documentation must be attached. -Plkl 1 4%11 '411119' Value�''WPM DRUG RECEIPT FOR 124415th Ave.,Longview,WA 98632 Ph.(360)423-3360 SAVE OR TAX RECORDS INSURANCE Pox, 816312 For. JOHN PARKS 10.03.08 CRN:A7086775978271 1335 3RD AVE#109 LONGVIEW,WA 98632 (360) 577-6684 MIRTAZAPINE SOLTAB 45MG 3 65862-0023-06 RICHARDS,JOHN E DR. ZHA COPAY: $14.01 11111 Ull I I 111111 II I II 111111 II Price Value at the smiling'0' 411Di' PIC Dian RECEIPT 124415th Ave.,Longview,WA 98632 Ph.(360)423-3360 SAVE FOR INSURANCE OR TAX RECORDS Rx# C816317 For. JOHN PARKS 10.03.08 CRN:81088774355681 1335 3RD AVE#109 LONGVIEW,WA 98632 (360) 577-6684 ZOLPIDEM TAB 10MG *** #30 NDC: 60505.2605-08 DR. RICHARDS,JOHN E ZHA COPAY: $2.31 II II III II III II I I III III0I0Il 11011 11 111111 I I II Pre Value at the smigng'0' P1e;DRUG RECEIPT 1244 15th Ave.,Longview,WA 98632 Ph.(360)423-3360 S INSURANCE OR TAX RECORDS Rx, C816311 For. JOHN PARKS 10.03-08 CRN:82086773025781 1335 3RD AVE#109 LONGVIEW,WA 98632 (360) 577-6684 ALPRAZOLAM 0.5MG TAB *** s0 NDC: 59762-3720-03 RICHARDS,JOHNE DR. ZHA COPAY: $6.28 1111111111111111111111111111111111111111 Price Pk • `ere SEND CLAIM TO: "410City of Renton Finance Dept.-Fire Pension 1055 South Grady Way Renton, WA 98057 C) 0Yt jiR CITY OF RENTON FIREMEN'S PENSION BOARD Pharmacy/Medical Claim Reimbursement Request 1) DATE / (7# 3Th ,-/-Re4j 2) DISABILITY RETIREE'S NAME (print) 91,21 Karl Strom 3) ADDRESS eol anion Ave.SE#14a Renton,WA 98059-517 4) DISABILITY AT TIME OF' KC i n`Livi–NT 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 retirement disability,provided that the expense is not covered by another plan,source or insurance coverage. Supporting documentation for all must be attached.) / 1 7/47n)3 tr-t) /-2,y2?-___ 7° 6) TOTAL AMOUNT OF CLAIM: $ � *3 .Vi 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: 614-23/n(-4-1-"r— Note: Supporting documentation must be attached. Rk • ,,kaie Niro SAM'S CLUB (425)793-7937 SAM'S CLUB (425)793-7937 901 SOUTH GRADY WAY 901 SOUTH GRADY WAY Pharmacy RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000 STROM,KARL B 10/03/2008 REFILL STROM,KARL B 10/03/2008 REFILL 15616 SE 143RD RENTON,WA 98055 15616 SE 143RD RENTON,WA 98055 RX:6682146 Ref#P QTY:30 DAW:0 DS:30 RX:6682146 Ref#P QTY: 30 DAW:0 DS:30 NDC:00378-1809-01 LEVOTHYROXIN 100MCG TAB MYL NDC:00378-1809-01 LEVOTHYROXIN 100MCG TAB MYL GRAVES,DANIEL NABP:4930613 GRAVES,DANIEL NABP:4930613 Patient Pay $4.00 Patient Pay $4.00 KARLOM B 1110 To Dm 15616 SE 143RD r J RENTON,WA 98055IIIII U i ri (425)271.8373 4 79312 76746 6 5. n Y 10/03/2008 (425)793-7937 �C Signature Required N RX:6682146 REF#P OC#465 923 861 076 592 384 107 659 238 10/03/2008 03:38:31 PM"• O Page No : 1 of 2 TOTAL: $4.00 a SAM'S CLUB (425)793-7937 $10.78 SAM'S CLUB (425)793-7937 $10.78 901 SOUTH GRADY WAY Pharmacy901 SOUTH GRADY WAY Pharmacy RENTON,WA 98055-0000 RENTON,WA 98055-0000 STROM,KARL B 10/03/2008 REFILL STROM,KARL B 10/03/2008 REFILL 15616 SE 143RD RENTON,WA 98055 15616 SE 143RD RENTON,WA 98055 RX: 6672060 Ref#7 QTY:60 DAW:0 DS:30 RX:6672060 Ref#7 QTY:60 DAW:0 DS: 30 NDC: 00378-0018-01 METOPROLOL 25MG TAB MYL NDC:00378-0018-01 METOPROLOL 25MG TAB MYL BROCKENBROUGH,ANDREW T NABP:4930613 BROCKENBROUGH,ANDREW T NABP:4930613 47901 47901 WHI AARP Patient Pay $3.00 WHI AARP Patient Pay $3.00 3o.Y STROM 111 11 i 1 11 111 Cr. D m 15616 SE 143RD r J RENTON,WA 98055 _ CC (425)271-8373 4 79312 76715 2 Q 10/03/2008 (425)793-7937 �. ``11 Signature Required N RX:6672060 REF=7 OC#355 923 871 076 592 884 107 659 238 L 10/03/2008 02:46:36 PM"' WHI 0 Page No : 1 of 2 TOTAL: $3.00 n SAM'S CLUB 9021 SOUT) H GRADY WAY $8.00 SAM'S CLUB (425)793-7937 SOUTH GRADY WAY $8.00 Pharmacy RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000 STROM,KARL B 10/03/2008 REFILL STROM,KARL B 10/03/2008 REFILL 15616 SE 143RD RENTON,WA 98055 15616 SE 143RD RENTON,WA 98055 RX:6683461 Ref#2 QTY:60 DAW:0 DS:30 RX:6683461 Ref#2 QTY: 60 DAW:0 DS:30 NDC: 54458-0976-07 ALLOPURINOL 100MG TAB INT NDC:54458-0976-07 ALLOPURINOL 100MG TAB INT BROCKENBROUGH,ANDREW T NABP:4930613 BROCKENBROUGH,ANDREW T NABP:4930613 47891 47891 - WHI AARP Patient Pay $7.00 WHI AARP Patient Pay $7.00 2 KARLOB v E. 00 15616 SE 143RD C J RENTON,WA 98055 _ CC (425)271-8373 4 79312 76714 5 5. ^ Y 10/03/2008 (425)793-7937 / Y Signature Required N RX:6683461 REF=2 OC#555 923 821 076 592 384 107 659 238 L 10/03/2008 02:46:23 PM.•• WHI O Page No : 1 TOTAL: $7.00 p P#4, I0 *se Noe SAM'S CLUB (425)793-7937 $18.54 SAM'S CLUB (425)793-7937 $18.54 901 SOUTH GRADY WAY 901 SOUTH GRADY WAY Pharmacy RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000 STROM,KARL B 10/03/2008 REFILL STROM,KARL B 10/03/2008 REFILL 15616 SE 143RD RENTON,WA 98055 15616 SE 143RD RENTON,WA 98055 RX:6678271 Ref#2 QTY:30 DAW:0 DS:60 RX:6678271 Ref#2 QTY: 30 DAW:0 DS:60 NDC: 00093-7153-98 SIMVASTATIN 10MG TAB TEV NDC:00093-7153-98 SIMVASTATIN 10MG TAB TEV BROCKENBROUGH,ANDREW T NABP:4930613 BROCKENBROUGH,ANDREW T NABP:4930613 47931 47931 WHI AARP Patient Pay $4.41 WHI AARP Patient Pay $4.41 5 STROM it B . 0 03 15616 SE 143RD J RENTON,WA 980551111111II 3 (425)271-8373 4 79312 76717 6 ,A 10/03/2008 (425)793-7937 Signature Required N RX:6678271 REF=2 OC#655 923 865 776 592 884 107 659 238 ' 4 8 10/03/2008 02:47:47 PM"• WHI Page No : 1 of 2 TOTAL: $4.41 tl SAM'S CLUB (425)793-7937 $10.00 SAM'S CLUB (425)793-7937 $10.00 901 SOUTH GRADY WAY 901 SOUTH GRADY WAY Pharmacy RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000 STROM,KARL B 10/03/2008 REFILL STROM,KARL B 10/03/2008 REFILL 15616 SE 143RD RENTON,WA 98055 15616 SE 143RD RENTON,WA 98055 RX:6683460 Ref#2 QTY:90 DAW:0 DS: 30 RX:6683460 Ref#2 QTY:90 DAW:0 DS: 30 NDC:00378-0232-01 FUROSEMIDE 80MG TAB MYL NDC:00378-0232-01 FUROSEMIDE 80MG TAB MYL MARTIN,MICHAEL M NABP:4930613 MARTIN,MICHAEL M NABP:4930613 47991 47991 WHI AARP Patient Pay $9.00 WHI AARP Patient Pay $9.00 5 . Ne 5 STROM 0 D m KARL BIII II I I II 15616 SE 143RD X J RENTON,WA 98055 _ CC (425)271-8373 4 79312 76718 3 Q 10/03/2008 (425)793-7937 ?+ n Y Signature Required N RX:6683460 REF=2 OC#155 923 881 076 592 884107 659 238 i 10/03/2008 02:47:54 PM... WHI 0 Page No : 1 of 2 TOTAL: $9.00 0`, SAM'S CLUB (425) 2SOUTH 37 WAY $25.46 SAM'S CLUB (425)793-7937 $25.46 901 901 SOUTH GRADY WAY Pharmacy RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000 STROM,KARL B 10/20/2008 REFILL STROM,KARL B • 10/20/2008 REFILL 15616 SE 143RD RENTON,WA 98055 15616 SE 143RD RENTON,WA 98055 RX:4412944 Ref# 1 QTY: 120 DAW:0 DS: 30 RX:4412944 Ref# 1 QTY: 120 DAW:0 DS: 30 NDC: 00406-0357-05 HYDROCO/APAP5-500MG TAB MAL NDC:00406-0357-05 HYDROCO/APAP5-500MG TAB MAL BROCKENBROUGH,ANDREW T NABP:4930613 BROCKENBROUGH,ANDREW T NABP:4930613 93281 93281 WHI AARP Patient Pay $12.48 WHI AARP Patient Pay $12.48 oSTROM KARL B III Il l 1 1 11 1 ii- 0 m 15616 SE 143RD CC J RENTON,WA 98055 CC (425)271-8373 4 79312 80615 8 10/20/2008 (425)793-7937 5. Signature Required N RX:4412944 REF=1 OC#155 923 405 476 592 384107 659 238 .i 10/20/2008 06:25:00 PM WHI O Page No : 1 of 2 TOTAL: $12.48 d P 11