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HomeMy WebLinkAboutFinal Agenda Packet lope vow CITY OF RENTON FIREMEN'S PENSION BOARD Regular Meeting 7th Floor-Mayor's Conference Room Thursday, June 18, 2009 2:00 P.M. 1. CALL TO ORDER 2. APPROVAL OF MINUTES OF MAY 21, 2009 3. CORRESPONDENCE 4. MONTHLY STATEMENT TO MAY 31, 2009 5. MONTHLY BILLS AND PENSION PAYMENTS 6. UNFINISHED BUSINESS 7. NEW BUSINESS 8. ADJOURNMENT liore 'err MINUTES FIREMEN'S PENSION BOARD CITY OF RENTON May 21, 2009 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 2:00 p.m. in the Mayor's office, 7th floor of Renton City Hall. In attendance were Board members Denis Law, Don Persson, Bruce Phillips, and Ray Barilleaux. Also in attendance: Jason Seth, Deputy City Clerk and acting Board Secretary, and Jill Masunago, Finance Department Representative. MINUTES APPROVAL MOVED BY PHILLIPS, SECONDED BY BARILLEAUX, THE PENSION BOARD APPROVE THE MINUTES OF THE APRIL 16, 2009, MEETING. CARRIED. MONTHLY STATEMENT The financial report as of April 30, 2009 was reviewed. Total cash/investment balance was $4,306,347.31. MONTHLY BILLS AND PENSION PAYMENTS MOVED BY PHILLIPS, SECONDED BY BARILLEAX, THE BOARD APPROVE THE PENSION/MEDICAL PAYMENTS FOR APRIL 2009, IN THE TOTAL AMOUNT OF $41,668.23. CARRIED. UNFINISHED BUSINESS Mr. Barilleaux stated that the death benefit has been brought in line with the LEOFF 1 benefit and explained that the spouses of retirees who married after retirement are now entitled to the death benefit. He noted that Karl Strom is the only retiree that this affects and that the change becomes effective in July. ADJOURNMENT MOVED BY BARILLEAUX, SECONDED BY PERSSON, THE MEETING OF THE FIREMEN'S PENSION BOARD BE ADJOURNED. CARRIED. Time: 2:09 p.m. 44")(-0 Jason Seth, Deputy City Clerk Acting Secretary, Firemen's Pension Board r CITY OF RENTON - FIREMEN'S PENSION FUND CASH & INVESTMENT ACTIVITY REPORT AS OF MAY 31, 2009 Fireman's Pension Fund Comparison of Cash and Investment Activity 6 - _. ❑2009 0 2008 5 m 0 4 0 0 N 3 O 2 4 111I J.! - 1 . Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec CURRENT 2009 2009 LAST YEAR 2008 2008 ACTIVITY: MONTH YTD BUDGET CURR MO ACTUAL ADJ BUDGET BEGINNING CASH/INV BALANCE $4,306,347.31 $4,265,991.35 $3,895,540 $4,514,867.86 $4,694,232.48 $4,203,347 RECEIPTS: Fire Insurance Premium Tax 106,622.90 106,622.90 90,000 85,949.42 85,949.42 75,000 Investment Interest 215.86 208,400.54 200,000 1,475.13 17,965.67 200,000 DISBURSEMENTS: Fire Pension 36,376.89 197,333.64 500,000 41,489.16 512,262.83 552,400 Fire Pension Medical 976.71 3,911.68 20,000 (2,899.29) 9,572.61 20,000 Office/Operating Supplies 0.00 0.00 475 0.00 372.78 459 Actuarial/Firemen's Pens 3,200.00 3,200.00 0 0.00 0.00 0 Reimb General/Clerical&Acct 983.00 4,920.00 11,801 829.00 9,948.00 9,948 ENDING CASH/INV BALANCE $4,371,649.47 $4,371,649.47 $3,653,264 $4,562,873.54 $4,265,991.35 $3,895,540 CURRENT PREVIOUS LAST YEAR LAST YEAR ACTIVITY: MONTH MONTH CURR MO PREV MO CASH $833,229.21 $767,927.05 $801,753.97 $753,748.29 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 2,984,096.96 2,984,096.96 3,206,796.27 3,206,796.27 TOTAL CASH AND INVESTMENTS $4,371,649.47 $4,306,347.31 $4,562,873.54 $4,514,867.86 The State Investment Pool interest 0-6658% 0.8905% 2.6998% 2.6998% H:\FINANCE\FINPLAN\FIREPEN\1_Fire_Pension_2009.xls\May09 Page 1 06/12/2009 Nue FIREMEN'S PENSION BOARD PENSION/MEDICAL PAYMENTS FOR JUNE, 2009 ANKENY, Charlie(Captain) $135.71 135.71 ASHURST, James (Assistant Chief) $4,820.50 - 4,820.50 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 Chief) - - GOODWIN, Charles (Captain) $4,231.00 3,443.57 7,674.57 GOODWIN, Donald (Firefighter) $1,018.60 1,018.60 HAWORTH, Constance(Widow) $2,792.83 2,792.83 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 Chief) - - MC LAUGHLIN, JACK(Battalion Chief) $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, John (Firefighter) $3,312.50 77.74 3,390.24 PHILLIPS, Bruce H. (Deputy Chief) $257.12 257.12 PRINGLE,Arthur(Captain) $481.28 481.28 PRINGLE, S.Joan (Widow) $2,399.37 2,399.37 RIGGLE, David E. (Firefighter D Step) $82.78 82.78 RUPPRECHT,Jim (Firefighter D Step) $117.72 117.72 SMITH, Leroy(Firefighter) $409.86 409.86 STROM, Karl (Firefighter) $3,191.50 91.95 3,283.45 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, Larry(Battalion Chief) $768.23 768.23 WILLIAMS,Alta (Widow) - - WOOTEN, Mari! n E. (Widow) $239.28 239.28 ,• • Prior Year Pension/Medical Payments: Total Pension Payments for June, 2008 41,489.16 Total Medical Bills Reimbursed in June, 2008 1,567.01 Total Expenses: Medical/Pension 43,056.17 406/12/2009 2009.XLS 06/12/2009 NW vni FIREMEN'S PENSION BOARD MEDICAL BILLS TO BE REIMBURSED IN JUNE, 2009 PAYMENT "'" * i»�"p^ �k l�i . , •. • ♦� m. �t -7�t*„y� „- "'", "ma f""Tx"-:41,: s r } d,"��`.wt�.rs.#��r.�`'��"�,6 lr�r�i�wlu��tr��.a-.c �`L�fi'.�6.�k.�un�m ,�ka'�'��: � ff,•,. James Ashurst 0.00 2 Charles Goodwin Bartell Drugs 04/27/09 133.91 2 Charles Goodwin Bartell Drugs 04/27/09 15.29 2 Charles Goodwin Bartell Drugs 04/27/09 9.89 2 Charles Goodwin Bartell Drugs 04/30/09 38.51 3 Charles Goodwin Bartell Drugs 04/30/09 361.76 3 Charles Goodwin Bartell Drugs 05/11/09 9.89 3 Charles Goodwin Bartell Drugs 05/27/09 194.36 4 Charles Goodwin Costco 06/03/09 79.98 5 Charles Goodwin Costco 06/03/09 2,599.98 3,443.57 Jack Haworth 0.00 7 John Parks Olympic Drug 05/01/09 8.41 7 John Parks Olympic Drug 05/01/09 1.39 7 John Parks Olympic Drug 05/01/09 3.89 7 John Parks Olympic Drug 05/05/09 0.75 7 John Parks Olympic Drug 05/05/09 5.66 7 John Parks Olympic Drug 05/05/09 46.69 7 John Parks Olympic Drug 05/05/09 4.67 7 John Parks Olympic Drug 05/05/09 6.28 77.74 9 Karl Strom Sam's Club 04/27/09 9.00 9 Karl Strom Sam's Club 04/27/09 9.00 9 Karl Strom Sam's Club 04/28/09 5.00 10 Karl Strom Sam's Club 04/28/09 16.97 10 Karl Strom Sam's Club 05/11/09 4.59 12 Karl Strom Sam's Club 05/19/09 5.00 12 Karl Strom Sam's Club 05/23/09 4.41 12 Karl Strom Sam's Club 05/23/09 3.00 13 Karl Strom Sam's Club 06/03/09 16.97 13 Karl Strom Sam's Club 06/04/09 13.42 13 Karl Strom Sam's Club 05/26/09 4.59 91.95 IP, "'r''` x y,. »" V. ', � " te '"''. u , a€€-4`* '',+ 3_2009 FP Medical.XLS Page 1 of 1 06/12/2009 `✓ SENDCLAIMTO: 'mCity of Renton Finance Dept.-Fire Pension 1055 South Grady Way Renton,WA 98057 4NTo� CITY OF RENTON FIREMEN'S PENSION BOARD Pharmacy/Medical Claim Reimbursement Request 1) DATE 6 Q / 2) DISABILITY RETIREE'S NAME (print) C Imo " 4, c0 - 1 A 3) ADDRESS Ida 4) DISABILITY AT TIME OF RETIREMENT � &�_i/4 - ,/i , 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 cove`,ge. Supporting documentation for all must be attached.) 6) TOTAL AMOUNT OF CLAIM: � 94 a , s Amount of total claim (above) that is related to the Retirement Disability: 7(Dc• ' a / b7 /.94 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: Supporting documentation must be attached. PMI „ ,i _j,_.4 7q/d 7 .„-------•1 d ...., : jj,,,,,....?..,,k.,, -- 1:,„„,,- 47/tie_ i(ovii, I , j ( , F81#1 ' efili (1-1 . /4 - 6-‘6141 6') I A) 1 BARTELL DRUGS ash' on's OEwn I ston � ` RX# 45-4W92207 OR. KATO I BARTELL DRUGS DATE: 04/27/09 N (425)255-9310 Washington's Own Drngatoresns Rxii 45-49225 E DR. KATO NAME: CHARLES GOODWIN DATE: 04/27/09 N (425)255-9310 1414 MONROE AVE NE#306 NAME: CHARLES GOODWIN FUROSEMIDE 40MG TABLET(*QIP) 1414 MONROE AVE NE#306 00603-3740-32 4443102784659 PANTOPRAZOLE TAB 40MG SUN REFILL 1 QUANTITY 30.00 62756-0580-81 4443104904659 BARTELL DRUGS PRICE= $10.99 REFILL NO QUANTITY 30.00 WITH SR THE AMOUNT DUE:WI q-0p BARTELL DRUGS PRICE= $143.99 BARTELL DRUGS#45 WITH SR THE AMOUNT DUE 4133.91 1331/ (425)793-1015 4700 NE 4TH STREET BARTELL DRUGS#45 RENTON,WA 98059 (425)793-1015 4700 NE 4TH STREET THANK YOU RENTON, WA 98059 WE TRULY APPRECIATE YOUR BUSINESS. TO PROVIDE YOU WITH THE BEST SERVICE POSSIBLE PLEASE DER 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 BARTELL DRUGS RXM r'as &n on's swn irugslore- BARTELL DRUGS 45- 49286 E DR. KATO DATE: 04/30/09 N (425)255-9310 BAR ons#wn# RX# 45- 492206 E DR. KATO NAME: CHARLES GOODWIN DATE: 04/27/09 N (425)255-9310 1414 MONROE AVE NE#306 NAME: CHARLES GOODWIN TRAMADOL 50MG TABLET(*APX) 1414 MONROE AVE NE#306 60505-0171-08 4491416314659 LISINOPRIL 5MG TABLET(*LUP) 1 .419REFILL NO QUANTITY 68180-0513-03 60.00 3403280497609 BARTELL DRUGS PRICE= $42.79 REFILL No QUANTITY 30.00 WITH SR THE AMOUNT DUE 418,11 J2gI S7 BARTELL DRUGS PRICE= $16.99 WITH SR THE AMOUNT DUE=$15.29 BARTELL DRUGS#45 (425)793-1015 BARTELL DRUGS#45 4700 NE 4TH STREET (425)793-1015 RENTON, WA 98059 4700 NE 4TH STREET RENTON,WA 98059 THANK YOU WE TRULY APPRECIATE YOUR BUSINESS. TO PROVIDE YOU THANK YOU WITH THE ABPE 24-48 OURS IN ADVANCE RDER YOUR WE TRULY APPRECIATE YOUR BUSINESS. TO PROVIDE YOU WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR REFILLS 24-48 HOURS IN ADVANCE 4fiyd --To -;e)D (di [poor � � � BA liEffll DRUGS —�.�.�•a, 'ngton9 RX# 45-431280 E DR.RIFFITH,ALIDA DATE: 04/30/09 R (425)899-3123 NAME: CHARLES GOODWIN 1414 MONROE AVE NE#306 CARBIDOPA/LEVODOPA 25MG/100M 00093-0293-01 3426577407609 — REFILL NO QUANTITY540.00 BARTELL DRUGS BARTELL DRUGS PRICE= $388.99 Fool Y n Zugt-OaRCF 3W.710 °R LORCHERALD WITH SR THE AMOUNT DUE= 361.76 DATE: 05/27/09 R (425)251-5110 NAME: CHARLES GOODWIN BARTELL DRUGS#45 14-14 MONROE AVE NE#306 (425)793-1015 4700 NE 4TH STREET AGGRENOX CAP 200/25 RENTON, WA 98059 00597-0001-60 4752511954659 THANK YOU REFILL 3 QUANTITY WE TRULY APPRECIATE YOUR BUSINESS TO PROVIDE YOU 60.00 WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR BARTELL DRUGS PRICE= $208.99 t_ REFILLS 24-48 HOURS IN ADVANCE WITH SR THE AMOUNT DUE:1.19 BARTELL DRUGS#45 6/36) (425)793-1015 4700 NE 4TH STREET BARTELL DRUGS RENTON,WA 98059 Washington's Own Drugstorennts D RX# 45-488364 E DR- LORCH,GERALTHANK YOU DATE: 05/11/09 R (425)251-5110 WE TRAPpgECAOUR BUSINESS. TO PROVIDE YOU WITH THE ULY BEST SERVITECE YPOSSIBLE PLEASE ORDER YOUR NAME: CHARLES GOODWIN REFILLSI24-4g HOURS IN ADVANCE 1414 MONROE AVE NE#306 ALLOPURINOL 100MG TABLET(PAR 49884 0602 1( 4612292904659 REFILL 4 QUANTITY 30.00 '61-)/1 / BARTELL DRUGS PRICE= $10.99 �' (0 WITH SR THE AMOUNT DUE 4a.89 BARTELL DRUGS#45 e06 (425)793-1015 4700 NE 4TH STREET RENTON,WA 98059 THANK YOU WE T • RULY APPRECIATE YOUR BUSINESS. TO PROVIDE YOU / WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR 11 REFILLS 24-48 HOURS IN ADVANCE TpI UNIVERSAL O C} c) 0 HEARINGAID CENTER SALES RECEIPT (LOC. #) 37345 1 111111 II 111111 SLIP PRINT HERE DATE: *F 396755 EARMOLD 39 *Order No. : 3734584 + *F 396755 EARMOLD 39 LOCATION: / • -lfce #-dpi�+ *Order No. : 3734584 TELEPHONE: c2O6 TOTAL 79 *VF EFT/DEBIT 79 SOLD TO CHANGE d n', /, 6:41:)(34)-L° n � ^ NAME L d I *TOTAL NUMBER OF ITEMS SOLD = 2 *CASHIER: GOLDA G REG4 MEMBERSHIP NUMBER * 6/03/2009 12:16 0006 79 0004 13: TELEPHONE (IQL•S- 7 a ITEM # DESCRIPTION 39 �� S� QUANTITY PRICE/EACH TOTAL C3 C 6i,461C-( a- ', c 7909 PAID BY COMMENTS: CHECK SUB-TOTAL CASH TAX aosico REDIT CARD TOTAL **PLEASE COMPLET )N FOR EARMOLD AND REPAIR PURCHASES ONLY. Form#HA04 5/07 Printed b PINK-MEMBER COPY GOLDENROD-SALES AUDIT 9009, ** 06 SOUTHCENTER MEMBER #111647762110 Order No. : 3734584 F 396755 EARMOLD 39.99 Order No. : 3734584 F 396755 EARMOLD 39.99 TOTAL VF EFT/DEBIT 79.98 XXXXXXXXXXXX0274 SWIPED 06/03/09 12:16 Seg#: 000003 Ref#: 000000 EFT/DEBIT Resp: AA FID Y: 44414 APPROVED AMOUNT: $79.98 0006 079 0000000133 0004 CHANGE .00 TOTAL NUMBER OF ITEMS SOLD = 2 FSA N/TAX AMT (F) 79.98 FSATA .00 TOTAL 79.98 CASHIER: GOLDA G REG# 79 [11Wil% 12:16 0006 79 0004 133 Thank You ! P 4 r P lease Com Aga i n COSTCO HEARINGAID CENTER 400 Costco DriveOS100 3652087 Tukwila,WA 98188 • (206)575-9654 e�Ci/1 /l_ �0 �1 1„ * MEMBER 1111647762110 b C11/� *F 419596 AVID 5 OPEN 1,299.99 NAME OF BUYER ** 06 S O U T H C E N T E R *Order No. : 3652087 MEMBERS41.7# MEMBER #111647762110 *F 419596 AVID 5 OPEN 1,299.99 1`F ` 6�7� J� *Order No. : 3652087 ADDR Order No. : 3652087 * TOTAL 2,599.98 r 0411/1 t.J� F 419596 AVIO 5 OPEN IIIMAL•L•> *vE Check/Member writn 2.599.98 CITY/STATE/ZIP� __ -7-7 8 . Order No. : 3652087 * CHANGE .00 ��S F 419596 AVIO 5 OPEN i11A0A1?�J PHONE# C/ *TOTAL NUMBER OF ITEMS SOLD = 2 i l2/ � /' /i a (d TOTAL limo goo C..ASHTFR: SAIDA A F'vG• 79 Quantity Item-d1 VF Check/Member With 2,599.98 14#6/O3/2(4O ,KPI 6 79 136Ie 133 CHANGE4 Right Ear { (q TOTAL NUMBER OF ITEMS ,SOLD - 2 .00 /3 $ ��4 R� Left Ear L �s' -/3 $ 4299,99 FSA N/TAX AMT (F) 2,599.98 $ Ear Molds FSA TAX .00 Com onents FSA TOTAL 2,599.98 $ p CASHIER: GOLDA G REG# 79 Accessories v,� ..._,F 12:19 0006 79 0005 133 $ Services Thank You! ! $ Please Come Again Condition of hearing aid 1R1Cvi Tax (if applicable) $ Hearing Aid Warranty Period IVICJ11111J 1__1 110 warranty $ Hearing Aid Damage Period Gag Months ❑ No warranty $ Ear Mold Warranty Period _ Months ❑ No warranty $ Component Warranty Period _ Months ❑ No warranty $ Accessories Warranty Period _ Months ❑ No warranty $ Hearing Aid Loss Period 4172-__CLi Months ❑ No warranty $� c?.?❑Check ❑Cash CI Credit Card , Oebit TO,,TAL $ , O 15TDAY TRIAL PERIOD: During the 60-day trial period following the dispensing date, you, the buyer, may return the hearing aid, ear mold, hearing aid component and any accessories as itemized above (together referred to as "hearing aid equipment") for any reason to receive a full refund provided you return the item to the Costco Hearing Aid Center in the same condition as when purchased, ordinary wear and tear excluded. WARRANTY POLICY: Beginning on the dispensing date for the time period(s) noted above, the hearing aid equipment you purchased is warranted by the manufacturer to cover any defects in materials and/or workmanship. DAMAGE OR LOSS ONE-TIME REPLACEMENT POLICIES: Beginning on the dispensing date for the time period(s) noted above, if the hearing aid you purchased is warranted for loss and/or damage, the manufacturer agrees to provide a one-time replacement of a new or refurbished comparable hearing aid for the same ear, at no additional charge. The Damage Policy covers hearing aids that are damaged beyond repair. The Loss Policy covers lost or stolen hearing aids. Hearing aids covered under these policies can be replaced one-time for either loss (if applicable) or damage (if applicable), but not both. If you find the original hearing aid after replacement, it becomes the property of the manufacturer and must be returned to the Costco Hearing Aid Center. The original manufacturer's warranty period will apply to the replacement hearing aid. Please note that the hearing aid replaced under the Damage or Loss Policy cannot be returned for a refund. ADVISEMENTS:The buyer has been advised at the outset of the buyer's relationship with the hearing instrument fitter/dispenser that any examination or representation made by a licensed hearing instrument fitter/dispenser in connection with the practice of fitting and selling of this hearing aid, or hearing aids, is not an examination, diagnosis or prescription by a person licensed to practice medicine in this State, and shall not be considered a medical examination, opinion or advice. The buyer has been advised that the hearing aid has been specifically built to fit the acoustic needs of the buyer's particular loss and is not intended to be used on any other ear except the one tested. Notice to Buyer: The hearing in tr ent fitter/dispenser has provided me with a copy of Washington's Notice to Buyer (WAC 246-828-290). Buyer's Initials: 17{1/ S- T. ._ __ . I— • .....1 at... nn n,..."-.4,-.1 T.:.,1 D.,.41,r1 RAnr,..+nr.+..rnr\Al.nrrnnfit rinmnno .nrl/nr I ncc ("inn- Nisi SENDCLAIMTO: '".' City of Renton Finance Dept.-Fire Pension 1055 South Grady Way Renton,WA 98057 U4cY O� a3 • YP�NT°$ CITY OF RENTON FIREMEN'S PENSION BOARD Pharmacy/Medical Claim Reimbursement Request 1) DATE \I v'j / of Z © O 2) DISABILITY RETIREE'S NAME (printf 1-..,,. Pi< r ,c 3) ADDRESS /3 3z '`illiVa /•#-/A a9 i.d r/` we. ggc32 4) DISABILITY AT TIME OF RETIREMENT JTO Ch kali(u X Pi j e c)s e_ al if eiis1 1l arch Ile-fn 4ndAy) x ! t`r`y pr'sil macs 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.) Medlcime -p,s-rSe-mac 4, 4 AnAGIof %:(5j 711 -1` a I. © �d t crn e- - 0 i Co ) (i 6) TOTAL AMOUNT OF CLAIM: $ ?' , I ti 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: I -+ f & ---)efrj-hd., Note: Supping documentation must be attached. II �' 1 RUG RECEIPT la, VfflabitUa RECEIPT - 124415th Ave.,Longview,WA 98632 Ph.(360)423-3366 SAVE FOR INSURANCE 124415th Ave.,Longview,WA 98632 Ph.(360)423-3360 SAVE FOR INSURANCE OR TAX RECORDS OR TAX RECORDS Ro# 855617 For JOHN PARKS Rx# 879020 For JOHN PARKS 5.01.09 CRN:A8095216150701 1335 3RD AVE#109 5-05.09 CRN:48095257645271 1335 3RD AVE#109 LONGVIEW,WA 98632 (360) 577-6684 LONGVIEW,WA 98632 (360) 577-6684 MIRTAZAPINE SOLTAB 45MG OMEPRAZOLE CAP 20MG *** DR.30 NDC:RICHARDS,JOHN E20023.06 ZHA COPAY: $8.41 DR.s0 NDC:RICHARDS,JOHNIE5.0118-43 ZHA COPAY: $5.66 lll II Ill Ill Illll I IIII 11111111 Illl 1111111 IIl Pd.c liii HI 11111111111 11011 II ll0ll 111111 II liii Pd., J J . J �`'wipeDam RECEIPT l''-irlh4PfebRuci RECEIPT 1244 15th Ave.,Longview,WA 98632 Ph.(360)423-3366 SAVE FOR INSURANCE 124415th Ave.,Longview,WA 98632 Ph.(360)423-3360 SAVE FOR INSURANCE OR TAX RECORDS OR TAX RECORDS Rx# C855616 For JOHN PARKS Rx# 879023 For: JOHN PARKS �� 5-01-09 CR5:86095212924551 1335 3RD AVE#109 5.05.09 CRN:42095257648361 1335 3RD AVE#109 LONGVIEW,WA 98632 (360) 577-6684 LONGVIEW,WA 98632 (360) 577-6684 ZOLPIDEM TAB 10MG *** $ SYMBICORT AER 160-4.5 #30 NDC: 60505-2605-08 #10.20 NDC: 00186-0370-20 DR. RICHARDS,JOHN E ZHA COPAY: $1.39 DR. RICHARDS,JOHN E ZHA COPAY: $46.69 llII III IIlll II I lII 011111 110 III III 111111.1 II Price II ll III 11111 II I III 11111111111111110111111 Nee I I Ott,'le aiDRUG RECEIPT 4220, Y' Me'miiln Cam RECEIPT 1244 15th Ave.,Longview,WA 98632 Ph.(360)423-3366 SAVE FOR INSURANCE 1244 15th Ave.,Longview,WA 98632 Ph.(360)423-3360 SAVE FOR INSURANCE OR TAX RECORDS OR TAX RECORDS Rx# 839587 RN:A309521798500�on JOHNPD ARKSRx# 879016 RN: For: JOHN 1335 PARKS VE 9 5-01-09 LONGVIEW,AVE 98632 (360) 577-6684 5.05-09 LONGVIEW,WA 98632 (360) 577-6684 LACTULOSE SOL 10GMI15 $ AMOXICICLAV 5001125MG TAB DR144NDC:RICHARDS,JOHN E31378-58 ZHA COPAY: $3.89 DR.2RICHARDS,JOHN E5.100200 ZHA COPAY: $4.67 1111111111 IU I I III 1111111111111 II IIIII 11111 Price 1111111111111111 111111111111111111111111 ff Price J I ( 120, Y' Y ►ioRVci RECEIPT °YiviritioR11fi RECEIPT 1244 15th Ave.,Longview,WA 98632 Ph.(360)423-3366 SAVE FOR INSURANCE 124415th Ave.,Longview,WA 98632 Ph.(360)423-3366 SAVE FOR INSURANCE OR TAX RECORDSOR TAX RECORDS Rx# 879018 For: JOHN PARKS Rx# C879017For: JOHN PARKS 5.05.09 CAN:88095254328191 1335 3RD AVE#109 5.05.09 CAN:89095257643621 1335 3RD AVE#109 LONGVIEW,WA 98632 (360) 577-6684 LONGVIEW,WA 98632 (360) 577-6684 PREDNISONE 20MG *** $ ALPRAZOLAM 0.5MG TAB *** DR.I0 NDC:RICHARDS,JOHNiE3.1477-05 ZHA COPAY: $0.75 DRfi0 NDC:RICHARDS,JOHN E2 3720.03 ZHA COPAY: $6.28 1111 IIIIIIIIIIIIII1111111111111111111111 Price 111111111111 IIIU liii 11111111111111111111 Pdc° J I *rev SENDCLAIMTO: `' City of Renton Finance Dept.-Fire Pension 1055 South Grady Way Renton, WA 98057 01�Y�� CITY OF RENTON FIREMEN'S PENSION BOARD Pharmacy/Medical Claim Reimbursement Request 1) DATE - —/ / — 2) DISABILITY RETIREE'S NAME (print) Karl Strom 201 Union Ave. SE Unit 142 • 3) ADDRESS I . � .. .._�� 4) DISABILITY AT TIME OF RETIREMENT 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.) 7po 6) TOTAL AMOUNT OF CLAIM: $ 114 -°- 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: c:Ir Note: Supporting documentation must be attached. Pig • Nee SAM'S CLUB �;5sOUTH GRADY WAY $10'00 SAM'S CLUB (425)793'- 7 $10.00 PharmacyRENTON,WA 98055-0000 901 SOUTH 98055RADY WAY Pharmacy RENTON,WA 98055-0000 STROM,KARL B 04/27/2009 REFILL STROM,KARL B 04/27/2009 REFILL 201 UNION AVE SE#142 RENTON,WA 98059 201 UNION AVE SE#142 RENTON,WA 98059 RX:6692403 Ref#P QTY:90 DAW:0 DS:90 RX:6692403 Ref#P QTY:90 DAW:0 DS:90 NDC:00781-2052-01 TERAZOSIN 2MG CAP SAN NDC:00781-2052-01 TERAZOSIN 2MG CAP SAN GRAVES,DANIEL NABP:4930613 GRAVES,DANIEL NABP:4930613 67331 67331 WHI AARP Patient Pay $9.00 WHI AARP Patient Pay $9.00 Y STROM 0 CO KARL B n0. 201 UNION AVE SE#142 F. CC J RENTON,WA 98059 H (425)271-8373 4 79313 25362 3 Cl) ACC 04/27/2009 (425)793-7937 ?� V' `L Signature Required N RX:6692403 REF#P OC#155 923 881 076 592 884 107 659 238 8 04/27/2009 12:05:49 PM... WHI G Page No : 1 of 2 TOTAL: $9.00 d SAM'S CLUB ) 901 SOUT7HH GRADY WAY $10'00 SAM'S CLUB )793-7937 90 SOUTH GRADY WAY $10.00 PharmaR 98055-0000 RENTON,WA 98055-0000 OM,KARL B04/27/2009 NEW STROM,KARL B 04/27/2009 NEW 201 UNION AVE SE#142 RENTON,WA 98059 201 UNION AVE SE#142 RENTON,WA 98059 RX:6704612 Ref# 1 QTY:90 DAW:0 DS:45 RX:6704612 Ref#1 QTY:90 DAW:0 DS: 45 NDC: 00378-0232-93 FUROSEMIDE 80MG TAB MYL NDC:00378-0232-93 FUROSEMIDE 80MG TAB MYL MARTIN,MICHAEL M NABP:4930613 MARTIN,MICHAEL M NABP:4930613 54191 54191 WHI AARP Patient Pay $9.00 WHI AARP Patient Pay $9.00 Y 0 2 STROM KARL B 111 11 1 1 II I II a' 0 m 201 UNION AVE SE#142 CC J RENTON,WA 98059 I`— fi (425)271-8373 4 79313 25361 6 IYY 04/27/2009 (425)793-7937 A Signature Required N RX:6704612 REF=1 OC#155 923 881 076 592 884 107 659 238 �. 04/27/2009 05:52:27 PM WHI G Page No : 1 of 2 TOTAL: $9.00 d _dition:92.Information Expires 07/18/2009 SAM'S CLUB (42793-7937 9015 SOUTH GRADY WAY $242.54 SAM'S CLUB s )793-7937 o 5SOUTH GRADY WAY $242.54 Pharmacy RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000 STROM,KARL B 04/28/2009 NEW STROM,KARL B 04/28/2009 NEW 201 UNION AVE SE#142 RENTON,WA 98059 201 UNION AVE SE#142 RENTON,WA 98059 RX:6704701 Ref# 11 QTY: 30 DAW:0 DS:30 RX:6704701 Ref# 11 QTY:30 DAW:0 DS:30 NDC:00074-4317-30 ZEMPLAR 1MCG CAP ABB , NDC:00074-4317-30 ZEMPLAR 1MCG CAP ABB BROCKENBROUGH,ANDREW T NABP:4930613 BROCKENBROUGH,ANDREW T NABP:4930613 30000172002093 30000172002093 WHI AARP/RES RX Patient Pay $5.00 WHI AARP/RES RX Patient Pay $5.00 2 STROM L KARL B II li I I II 1 ,0 0 CO LIONAVESE#142 N CC J N,WA 98059 C (425)271-8373 4 79313 25937 3 009 (425)793-7937 - Signature Required N 704701 REF=11 OC#355 923 851 076 534 103 107 659 238 8 04/28/2009 02:24:23 PM•'• RES G Page No : 1 of 2 TOTAL: $5.00 a IAS1 err Nage . Database Edition:92.Information Expires 07/162009 SAM'S CLUB 9015 SOUTH GRADY WAY)793-7937 $37.78 SAM'S CLUB 9015 SO )793-7937 UTH GRADY WAY $37.78 Pharmacy RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000 STROM,KARL B 04/28/2009 NEW STROM,KARL B 04/28/2009 NEW 201 UNION AVE SE#142 RENTON,WA 98059 , 201 UNION AVE SE#142 RENTON,WA 98059 RX:4416064 Ref#3 QTY: 180 DAW:0 DS:30 RX:4416064 Ref#3 QTY: 180 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 11611 11611 • WHI AARP Patient Pay $16.97 WHI AARP Patient Pay $16.97 2 KAR OM III 11 1 1 11 11 I 1111 `O 0 m 201 UNION AVE SE#142 CO CC —I RENTON,WA 98059 C I cc (425)271.8373 4 79313 25931 1 04/28/2009 (425)793-7937 Signature Required N RX:4416064 REF=3 OC#455 923 494 876 592 384 107 659 238 ': 04/28/2009 02:24:15 PM*" WHI0 Page No : 1 of 2 TOTAL: $16.97 d • SAM'S CLUB 901(425 SOUTH GRADY WAY SAM'S CLUB 9015SOUTH) �GRADY WAY 7 $8.00 Pharmacy RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000 STROM,KARL B 05/11/2009 REFILL STROM,KARL B 05/11/2009 REFILL 201 UNION AVE SE#142 RENTON,WA 98059 201 UNION AVE SE#142 RENTON,WA 98059 RX:6697947 Ref#2 QTY:60 DAW:0 DS:30 RX:6697947 Ref#2 QTY:60 DAW:0 DS:30 NDC: 16714-0041-01 ALLOPURINOL 100MG TAB NOR NDC: 16714-0041-01 ALLOPURINOL 100MG TAB NOR BROCKENBROUGH,ANDREW T NABP:4930613 BROCKENBROUGH,ANDREW T NABP:4930613 25191 25191 WHI AARP Patient Pay $4.59 WHI AARP Patient Pay $4,59 J Y STROM 00 m KARL B a 201 UNION AVE SE#142 CC J RENTON,WA 98059 C (425)271-8373 4 79313 28884 7 CO 05/11/2009 (425)793-7937 ). Signature Required N RX:6697947 REF=2 OC#655 923 869 176 592 384 107 659 238 05/11/2009 11:01:49 AM WHI O Page No : 1 TOTAL: $4.59 a 1.Arefe ID Nor SEND CLAIM TO: '4400" City of Renton Finance Dept.-Fire Pension 1055 South Grady Way Renton,WA 98057 O��Y 0 IR a CITY OF RENTON FIREMEN'S PENSION BOARD Pharmacy/Medical Claim Reimbursement Request 1) DATE 2) DISABILITY - v Karl Strom �'.= 201 Union Ave.SE Unit 142 3) ADDRESS _ Renton,WA 98059-5177 4) DISABILITY AT TIME OF RETIREMENT 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.) -S7qs Cf /c h 3, 6-- 5M 1S C../( ' y 3c1'6) TOTAL AMOUNT OF CLAIM: $ 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. r� Signature: "211h dt Ley, Note: Supporting documentation must be attached. P.6(&6- 11 • NW err Database Edition:92.Information Expires 06/18/2009 SAM'S CLUB (425)793-7937 $242.54 SAM'S CLUB (425)793-7937 $242.54 901 SOUTH GRADY WAY 901 SOUTH GRADY WAY Pharmacy RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000 STROM,KARL B 05/19/2009 REFILL STROM,KARL B 05/19/2009 REFILL 201 UNION AVE SE#142 RENTON,WA 98059 201 UNION AVE SE#142 RENTON,WA 98059 RX:6704701 Ref# 10 QTY:30 DAW:0 DS:30 RX:6704701 Ref# 10 QTY: 30 DAW:0 DS:30 NDC: 00074-4317-30 ZEMPLAR 1 MCG CAP ABB NDC:00074-4317-30 ZEMPLAR 1 MCG CAP ABB BROCKENBROUGH,ANDREW T NABP:4930613 BROCKENBROUGH,ANDREW T NABP:4930613 30000175507468 30000175507468 WHI AARP/RES RX Patient Pay $5.00 WHI AARP/RES RX Patient Pay $5.00 5 STROM KARL B111 11111111HOa 0 m 201 UNION AVE SE#142 CC --1 RENTON,WA 98059 3 I"'" (425)271-8373 4 79313 32171 1 A 05/19/2009 (425)793-7937 Signature Required N RX:6704701 REF=10 OC#355 923 851 076 534 103 107 659 238 05/23/2009 02.29:49 PM WHI/RES 0 Page No : 1 of 2 TOTAL: $5.00 a SAM'S CLUB (4 5SOUTH GRADY WAY $18.54 SAM'S CLUB (42)901 UT-7937 H GRADY WAY $18.54 901Pharmacy RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000 STROM,KARL B 05/23/2009 REFILL STROM,KARL B 05/23/2009 REFILL 201 UNION AVE SE#142 RENTON,WA 98059 201 UNION AVE SE#142 RENTON,WA 98059 RX:6702400 Ref#4 QTY:30 DAW:0 DS:30 RX:6702400 Ref#4 QTY:30 DAW:0 DS: 30 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 08051 08051 WHI AARP Patient Pay • $4.41. WHI AARP Patient Pay $4:41 STROM a KARL B' III 0 m 201 UNION AVE SE#142 /� 1i. J RENTON,WA 98059 (425)271-8373 4 79313 32134 6 CO^ 05/23/2009 (425)793-7937 Signature Required N RX:6702400 REF=4 OC#655 923 865 776 592 884 107 659 238r. 05/23/2009 11:57:39 AM WHI O Page No : 1 of 2 TOTAL: $4.41 0- Database Edition:92.Information Expires 06/18/2009 SAM'S CLUB (425)793-7937 $4.00 SAN'S CLUB (425)793-7937 $4.00 901 SOUTH GRADY WAY 901 SOUTH GRADY WAY Pharmacy RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000 STROM,KARL B 05/23/2009 REFILL STROM,KARL B 05/23/2009 REFILL 201 UNION AVE SE#142 RENTON,WA 98059 201 UNION AVE SE#142 RENTON,WA 98059 RX:6702397 Ref#4 QTY:30 DAW:0 DS: 30 RX:6702397 Ref#4 QTY:30 DAW:0 DS:30 NDC: 00378-0018-91 METOPROLOL TART 25MG TAB MY NDC:00378-0018-91 METOPROLOL TART 25MG TAB MY BROCKENBROUGH,ANDREW T NABP:4930613 BROCKENBROUGH,ANDREW T NABP:4930613 32701 32701 WHI AARP Patient Pay $3.00 WHI AARP Patient Pay $8.00 •2 STROM m KARL B IIIII20 m 201 UNION AVE SE#142 co CC ._J RENTON,WA 98059I = (425)271-8373 4 79313 32169 8 V^' 05/23/2009 (425)793-7937 - Signature Required N RX:6702397 REF=4 OC#555 923 871 076 592 388 107 659 238 05/23/2009 02:17:30 PM"' WHI G Page No : 1 of 3 TOTAL: $3.00 d PA-64" (z • SAM'S CLUB (41 s793-7937 WAY �+ $37.78 SAM'S CLUB (25SOUTH 1.7GWAY $37.78 Pharmacy. RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000 STROM,KRL B 06/03/2009 REFILL STROM,KARL B 06/03/2009 REFILL 201 UNION AVE SE#142 RENTON,WA 98059 201 UNION AVE SE#142 RENTON,WA 98059 RX:4416064 Ref#2 QTY: 180 DAW:0 DS:30 RX:4416064 Ref#2 QTY: 180 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 21961 21961 WHIAARP Patient Pay $t6,97 WHIAARP Patient Pay $16.97 i STRQM KARL B a 0 CO 201 UNION AVE SE#142 C+ J RENTON,WA 98059 H (425)271-8373 4 79313 34692 9 V, rA Y 06/03/2009 (425)793-7937 5. Signature Required N RX:4416064 e. REF=2 OC#455 923 494 876 592 384107 659 238 ''- 06/03/2009 07:08:20 PM WHI O Page No : 1 of 2 TOTAL: $16.97 a. SAM'S CLUB 901 SOUTH GRADY WAY)793-7937 72 SAM'S CLUB 9015 SOUTH GRADY WAY 7 -7937 $45.72 Pharmacy RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000 STROM,KARL B 06/04/2009 NEW STROM,KARL B 06/04/2009 NEW 201 UNION AVE SE#142 RENTON,WA 98059 201 UNION AVE SE#142 RENTON,WA 98059 RX:4416544 Ref#0 QTY:30 DAW:0 DS:30 RX:4416544 • Ref#0 QTY:30 DAW: 0 DS:30 NDC: 00093-0074-01 ZOLPIDEM 10MG TAB TEV NDC:00093-0074-01 ZOLPIDEM 10MG TAB TEV GRAVES,DANIEL NABP:4930613 GRAVES,DANIEL NABP:4930613 79361 79361 WHI AARP Patient Pay $13,42. WHI AARP Patient Pay $13.42 ii STROM KARL IIIil. 0 201 UNION AVE SE#142 Cr m RENTON,WA 98059 A/ CC • (425)271-8373 4 79313 34691 2 `/ 06/04/2009 (425)793-7937 Signature Required N RX:4416544 REF=0 OC#155 923 475 676 592 384 107 659 238 'L.L 06/04/2009 05:09:05 PM WHI O Page No : 1 of 2 - TOTAL: $13.42 a SAM'S CLUB 901(425)793-7937 SOUTH GRADY WAY $8-00SAM'S CLUB ��SOUT793-7937 RADY WAY Pharmacy RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000 STROM,KARL B 05/26/2009 REFILL STROM,KARL B 05/26/2009 REFILL 201 UNION AVE SE#142 RENTON,WA 98059 201 UNION AVE SE#142 RENTON,WA 98059 RX:6697947 Ref# 1 QTY:60 DAW:0 DS:30 RX:6697947 Ref# 1 QTY:60 DAW:0 DS:30 NDC: 16714-0041-01 ALLOPURINOL 100MG TAB NOR ' NDC: 16714-0041-01 ALLOPURINOL 100MG TAB NOR BROCKENBROUGH,ANDREW T NABP:4930613 BROCKENBROUGH,ANDREW T NABP:4930613 40911 40911 WHI AARP Patient Pay $4.59, , WHI AARP Patient Pay .. $459. S Y KAR B III II I I 1111 1 a 201 UNION AVE SE#142 0CC m RENTON,WA 98059 CO (425)271-8373 4 79313 32133 9 05/26/2009 (425)793-7937 rX Signature Required N RX:6697947 REF=1 OC#655 923 869 176 592 384 107 659 238 '8 05/26/200910:00:03 AM••• WHI c Page No : 1 TOTAL: $4.59 p`, -1706( 3