HomeMy WebLinkAboutFinal Agenda Packet ,
Now Now
CITY OF RENTON
FIREMEN'S PENSION BOARD
Regular Meeting
7th Floor-Mayor's Conference Room
Thursday, July 16, 2009
2:00 P.M.
1. CALL TO ORDER
2. APPROVAL OF MINUTES OF JUNE 18, 2009
3. CORRESPONDENCE
a. Cost of Living Increase - Widows
b. New Survivor Benefit Legislation- HB 1506
4. MONTHLY STATEMENT TO JUNE 30, 2009
5. MONTHLY BILLS AND PENSION PAYMENTS
6. UNFINISHED BUSINESS
7. NEW BUSINESS
8. ADJOURNMENT
fir► *iv
MINUTES
FIREMEN'S PENSION BOARD
CITY OF RENTON
June 18, 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 Mayor Denis Law at
2:00 p.m. in the Mayor's Conference room, 7th floor of Renton City Hall. In attendance were Board
members Denis Law, Don Persson, Bruce Phillips and Bonnie Walton. Also in attendance was Jill
Masunaga, Finance Department representative.
MINUTES APPROVAL
MOVED BY PHILLIPS, SECONDED BY PERSSON, THE PENSION BOARD APPROVE THE
MINUTES OF THE MAY 21, 2009, MEETING. CARRIED.
MONTHLY STATEMENT
The financial report as of May 31, 2009, was reviewed. Total cash/investment balance was
$4,371,649.47.
MONTHLY BILLS AND PENSION PAYMENTS
MOVED BY PHILLIPS, SECONDED BY PERSSON, THE BOARD APPROVE THE
PENSION/MEDICAL PAYMENTS FOR JUNE 2009, IN THE TOTAL AMOUNT OF $38,466.90
TO BE PAID FROM THE FIREMEN'S PENSION FUND. CARRIED.
UNFINISHED BUSINESS
Regarding survivor benefits, Bonnie Walton offered to research the impacts of recent State
legislation affecting certain Firemen's Pension members.
ADJOURNMENT
MOVED BY PHILLIPS, SECONDED BY PERSSON, THE MEETING OF THE FIREMEN'S
PENSION BOARD BE ADJOURNED. CARRIED. Time: 2:05 p.m.
6(41.: 4. Idatter,
Bonnie Walton
Firemen's Pension Board Secretary
ti�Y o ADMINISTRATIVE, JUDICIAL, AND
_c LEGAL SERVICES DEPARTMENT
�` Office of the City Clerk
�N�1/4., MEMORANDUM
DATE: July 10, 2009
TO: Members, Firemen's Pension Board
FROM: Bonnie Walton, City Clerk/Board Secretary & Member
SUBJECT: Cost of Living Increase Payable July 2009 - Widows
Washington State Law (RCW 41.18.104) requires that the Firemen's Pension Board meet each
year for the purpose of adjusting benefit allowances for widows of firemen pensioned prior to
the LEOFF Act (March 1970). The Board must determine benefits according to the increase in
the Consumer Price Index for the previous calendar year for the Seattle, Washington, area as
compiled by the Bureau of Labor Statistics of the United States Department of Labor.
The Bureau has updated its form for this year and has reported a 4.2% annual increase in the
CPI percentage for All Urban Consumers in the Seattle area for 2008. A copy of the report is
attached.
I recommend that the Board adopt the 4.2% increase, effective July 1, 2009, and paid July 31,
2009.
cc: Iwen Wang, FIS Administrator
Bureau of Labor Statistics Data Page 1 of 1
• •.4 • op,-• v-•
wuvw.b1s,gov Search: All BLS.gov for: mr1.1
„j100125YEARS Newsroom I Tutorials I Release Calendar
TA BUREAU OF LABOR STATISTICS
Home Subject Areas DatahaSeS TableS Publications Economic Releases A-Z Index I About BLS
7/ 77 77 „
Databases
Change Output Options: From 1999 To: 2009
[ include graphs More Farr/letting Options wig*
Data extracted on: July 10, 2009 (2:08:38 PM)
Consumer Price Index - All Urban Consumers
12 Months Percent Change
Series Id: CUURA423SA0
Not Seasonally Adjusted
Area: Seattle-Tacoma-Bremerton, WA
Item: All items
Base Period: 1982-84-100
Year Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Annual HALF1 HALF2,
1999 2.5 3.5 3.1 2.9 3.2 3.0 3.0 3.0 3.0
2000 3.2 3.3 3.8 4.0 4.2 4.1 3.7 3.3 4.1
2001 4.5 3.6 4.0 3.6 3.2 2.5 3.6 4.0 3.2
2002 2.0 2.5 1.7 1.9 1.6 2.1 1.9 2.1 1.8
2003 2.0 1.9 1.2 2.2 1.5 0.5 1.6 1.8 1.5
2004 1.2 1.0 1.9 0.1 1.4 2.1 1.2 1.3 1.2
2005 2.1 3.6 2.3 2.7 3.5 3.0 2.8 2.7 3.0
2006 3.0 3.0 4.2 4.9 3.2 4.2 3.7 3.3 4.1
2007 4.0 4.0 3.5 3.0 4.1 4.6 3.9 3.9 3.8
2008 4.7 3.4 5.8 5.4 3.4 1.7 4.2 4.6 3.8
2009 1.4 1.2
ss
Quick Links
Tools Calculators Help Info
5 At a Glance Tables 5 Inflation 5' Help&Tutcinais G What's New
5 Economic News Releases 5 Location Quotient 5 A to Z Index 6 Careers @ BLS
5 Databases&Tables 5 Injury And Illness 5 FAQs Find It! DOL
0 Maps & Glossary U Join our Mailing Lists
5 About BLS a Privacy& Security
a Contact Us a Linking&Copyright Information
fLeatiently_45k.gli_Qttg$tiQrrs FrAteOpirjg Infgroatiglii A CUStOilleTSATvgy 1214'99-it t-4.)
OBreatt of Labor Statistics 2 Massachusetts'Avenue.HE mbvshingtorl,Dc 202/2-000/
www. 1S.90v, T4:lepttole:k.202)691- 200 Do you hove, ,f),_atriirtutrsti,007 ,
, •
http://data.bls.gov/PDQ/servlet/SurveyOutputServlet 07/10/2009
r.re
From: Bonnie Walton
Sent: Tuesday, July 07, 2009 5:26 PM
To: Denis Law; Ray Barilleaux; Bruce Phillips; Don Persson
Cc: Jill Masunaga
Subject: Firemen's Pension - New Survivor Benefit Legislation
Attachments: TempHouseBill ltrs 7-7-09.doc
Expires: Sunday, January 03, 2010 12:00 AM
Renton Firemen's Pension Board Members:
Regarding House Bill 1506, as approved by the State Legislature this year: This Bill,
regarding Firefighters--Survivor Benefits, amends RCW 41.18 and goes into effect on July 26,
2009. In a nutshell this new legislation allows:
1) Survivor benefits to continue lifelong, even if the survivor remarries, and
2) Any retired firefighter married to a spouse ineligible for survivor benefits to choose an
actuarially reduced benefit adopted by the Board. Upon death of the retired firefighter, the
reduced retirement allowance will be continued through out the life of the surviving spouse.
If the retiree's spouse predeceases the retiree, and if the retiree provides the Board proper
proof of the death, the retiree's unreduced pension allowance will be payable from the
beginning of the month following the date of death.
We can discuss this further at our meeting next week, but what is interesting is that the
legislation as adopted is missing a few elements. One major thing is that it fails to
indicate how the actuarially reduced benefit should be calculated! Fortunately other FP
Boards and Clerks in the State are also questioning this and are pursuing answers, with some
trying to contact the initiators of the Bill. I should be receiving more information and
will share it with you as this evolves. Some think the State is going to need to enact an
amendment to this legislation to fill in the missing information.
In the meantime, I will send letters out tomorrow to the affected FP members so they are
aware. Drafts of the two letter versions are attached for your review. Please contact me if
you have questions or concerns; otherwise we can discuss further at next week's FP Board
meeting.
Respectfully,
Bonnie Walton
City Clerk and
FP Board Member & Secretary
City of Renton
425-430-6502
1
WIDOW LETTER
July 8, 2009
«FirstName» «LastName»
«Address»
«CityandState» «Zip»
Dear Mrs. «LastName»:
House Bill 1506 was recently passed into legislation effective July 26, 2009. This bill
affects your City of Renton RCW 41.18 pension benefits for survivors of firefighters
who retired under, or retain benefit comparisons under, the Firefighters' Relief and
Pensions (FRP) Act.
One of the sections of this bill removes language that currently causes the
survivor's benefit to cease if the surviving spouse remarries. Therefore.
even if you remarry, you will continue to receive your survivor's benefit
for the remainder of your lifetime.
If you have any questions regarding this provision, please contact me at (425) 430-
6502.
Sincerely,
Bonnie I. Walton
City Clerk and
Firemen's Pension Board Member and Secretary
Nor
RETIREE LETTER
July 8, 2009
«FirstName» «LastName»
«Address»
«CityandState» «Zip»
Dear«FirstName» «LastName»:
House Bill 1506 was recently passed into legislation effective July 26, 2009. This bill affects your City of
Renton RCW 41.18 pension benefits for survivors of firefighters who retired under, or retain benefit
comparisons under, the Firefighters' Relief and Pensions (FRP)Act.
1. This bill removes language that currently causes the survivor's benefit to cease if the surviving spouse
remarries,thus allowing the benefit to continue for the lifetime of the survivor.
2. This bill also allows any retired firefighter married to a spouse ineligible for survivor benefits to choose
an actuarially reduced benefit adopted by the Board. Upon death of the retired firefighter, the reduced
retirement allowance shall be continued throughout the life of the surviving spouse. If the retiree's spouse
predeceases the retiree, and if the retiree provides the Board proper proof of the death, the retiree's
unreduced pension allowance will be payable from the beginning of the month following the date of death.
If you were married to your current spouse after your retirement with the City of Renton, or if you were
married to your current spouse less than 5 years prior to your"service retirement", you are eligible to take
a reduction in your City of Renton pension allowance and add your spouse as your beneficiary. You have
until July 26, 2010, to make this election to reduce your City of Renton pension and add your spouse as
your beneficiary.
Please contact Bonnie Walton at the City of Renton City Clerk's Office to obtain an election form. Due to
incomplete direction in HB 1506, we do not have all the details regarding the amount or implementation of
the reduction. We are researching this issue; however, and by completing and returning the form, you will
be showing your intention to avail yourself of this option. Completing the form prior to knowing the
amount of the reduction will not obligate you at this time, but will protect your rights.
Sincerely,
Bonnie I. Walton
City Clerk and
Firemen's Pension Board Secretary
Enclosure: HB 1506
CITY OF RENTON - FIREMEN'S PENSION FUND
CASH & INVESTMENT ACTIVITY REPORT
AS OF JUNE 30, 2009
Fireman's Pension Fund Comparison of Cash and Investment Activity
6 _..l
❑2009 ❑2008
5 —
m — —
0 4
o
0
N
g 3
0
2
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 $4,371,649.47 $4,265,991.35 $3,895,540 $4,562,873.54 $4,694,232.48 $4,203,347
RECEIPTS:
Fire Insurance Premium Tax 0.00 106,622.90 90,000 0.00 85,949.42 75,000
Investment Interest 222.83 208,623.37 200,000 1,470.01 17,965.67 200,000
DISBURSEMENTS:
Fire Pension 36,853.64 232,187.28 500,000 41,489.16 512,262.83 552,400
Fire Pension Medical 3,613.26 7,524.94 20,000 1,567.01 9,572.61 20,000
Office/Operating Supplies 0.00 0.00 475 0.00 372.78 459
Actuarial/Firemen's Pens 0.00 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 $4,330,422.40 $4,333,405.40 $3,653,264 $4,520,458.38 $4,265,991.35 $3,895,540
CURRENT PREVIOUS LAST YEAR LAST YEAR
ACTIVITY: MONTH MONTH CURR MO PREV MO
CASH $794,002.14 $833,229.21 $759,338.81 $801,753.97
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 $4,332,422.40 $4,371,649.47 $4,520,458.38 $4,562,873.54
The State Investment Pool interest 0.7396% 0.6658% 2.2933% 2.6998%
H:\FINANCE\FINPLAN\FIREPEN\1_Fire_Pension_2009.xls\Jun09 Page 1 07/10/2009
err vn.
FIREMEN'S PENSION BOARD
PENSION/MEDICAL PAYMENTS FOR JULY, 2009
771 '` ° ` ' 1, 4.
ANKENY, Charlie(Captain) $135.71 135.71
ASHURST, James (Assistant Chief) $4,820.50 568.27 5,388.77
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 - 4,231.00
GOODWIN, Donald (Firefighter) $1,018.60 1,018.60
* HAWORTH, Constance(Widow) $2,910.13 2,910.13
HAWORTH, Jack(Firefighter) $3,191.50 - 3,191.50
HENRY, William, Jr. (Captain) $1,339.58 1,339.58
HURST, Gerald (Firefighter) $543.59 543.59
JONES, Evelyn M. (Widow) $250.62 250.62
LARSON, William (Firefighter) - -
LAVALLEY, Theodele(Captain) $360.94 360.94
MATTHEW, James (Deputy 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 - 3,312.50
PHILLIPS, Bruce H. (Deputy Chief) $257.12 257.12
PRINGLE, Arthur(Captain) $481.28 481.28
* PRINGLE, S. Joan (Widow) $2,500.14 2,500.14
RIGGLE, David E. (Firefighter D Step) $82.78 82.78
RUPPRECHT, Jim (Firefighter D Step) $117.72 117.72
SMITH, Leroy(Firefighter) $409.86 409.86
STROM, Karl (Firefighter) $3,191.50 79.93 3,271.43
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, Marilyn E. Widow $239.28 239.28
« c p rya �''' ,y� � za ....w y9 y : �, vv � Y'°' �+ ✓5'; a:, 4'uw. a
* Received a 4.2% CPI increase effective July 1 per RCW 41.16.145.
Prior Year Pension/Medical Payments:
Total Pension Payments for July, 2008 41,489.16
Total Medical Bills Reimbursed in July, 2008 1,567.01
Total Ex.enses: Medicali Pension 43,056.17
4_SUMMARY 2009.XLS 07/10/2009
Awe Novo
FIREMEN'S PENSION BOARD
MEDICAL BILLS TO BE REIMBURSED IN JULY, 2009 PAYMENT
. a,.7,_; „TM ,., 11' "�:I . .. {p er.•.'.r ta.,. I' ..s.. 1
2 James Ashurst Safeway 04/18/09 102.15
2 James Ashurst Safeway 05/05/09 13.26
2 James Ashurst Safeway 05/05/09 147.40
2 James Ashurst Safeway 05/05/09 89.98
2 James Ashurst Safeway 05/22/09 13.99
2 James Ashurst Safeway 05/28/09 102.15
3 James Ashurst Safeway 06/02/09 99.34
568.27
Charles Goodwin 0.00
Jack Haworth 0.00
John Parks 0.00
5 Karl Strom Sam's Club 06/19/09 9.00
5 Karl Strom Sam's Club 06/19/09 5.00
5 Karl Strom Sam's Club 06/19/09 8.37
6 Karl Strom Sam's Club 06/19/09 4.59
6 Karl Strom Sam's Club 06/20/09 3.00
6 Karl Strom Sam's Club 06/29/09 9.00
7 Karl Strom Sam's Club 07/01/09 16.97
7 Karl Strom Department of Veterans Affairs 06/03/09 24.00
79.93
u v'%.iFx..w..w �1¢�a-.,.�,5,a" � ✓-.::w.�iuu :,lnSAxw o-�k.. .' �;, �'��aw �:., sr.,X'�.1w.'+'.._ ! ,r .._„u,.Ls..w..>..xwsr e..i, ?d,'t,.wv�,.`w .,w,e i �.;�,.
3_2009 FP Medical.XLS Page 1 of 1 07/10/2009
""''' SEND CLAIM TO: `°'1 City of Renton
Finance Dept.-Fire Pension
1055 South Grady Way
Renton, WA 98057
S-Y 0
NER
�•NTa�
CITY OF RENTON
FIREMEN'S PENSION BOARD
Pharmacy/Medical Claim Reimbursement Request
1) DATE JUNE 29 2009
2) DISABILITY RETIREE'S NAME (print) JAMES F. ASIIURST
3) ADDRESS 223 GARDEN AVF, ts' # RENTON WA 98057
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.)
MEDICATION FOR ABOVE
6) TOTAL AMOUNT OF CLAIM: $ 5 b 8 .2 7
Amount of total claim (above) that is related to the Retirement Disability: $ 3 78- 9 5
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.
17A H
in1R KNRAACY ftil IPsI IBJ$ ACY
RENTON,WA 98055 RENTON,WA 98055
5 (425)226-0325 1 (425)226-0325
Official Receipt- Please retain for tax or insurance fficiat 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 . GRAVES,DANIEL
17900 TALBOT RD S [RF] DR17900 TALBOT RD S [RF]
RENTON,WA 98055 AskAF RENTON,WA 98055 AskAF
Rx:6710376 Apr 18, 2009 Safety Cap: Yes Rx:6721082 May 05, 2009 Safety Cap: Yes
PANTOPRAZOLE 40MG TAB TAB
Qty:30 TAB METOPROL TAR 50MG TAB (TEVA)Qty: 100 TAB
Generic for:PROTONIX 40MG TA
Ref:30000034107139 NDC:00008-0607.01 BBAI Ref:300)0035550247 NOD:00093-0733.10 HSGI
REGENCE BS WASHINGTON Cash Price: 134.49 REGENCE BS WASHINGTON Cash Price: 13.26
Amount Due: $102.15 Amount Due: $13.26
H II I I I 111110111 IllliIII Rx I REFILL
�SYOUR
PRESCRIPTIONS III II III IIIIIIIIIIIIIIIIIIIIH �iRx1 ^REFILL RPRSCR/PTI0NS
�® �B SAFEWAYOUY.ECOM
00000068710 102 O'132r . r r i —Ili■ AcyTM
NOBODY
FOR
DPM ACY
RENTON,WA 98055
# (425)226-0325
PHARMACY
fflcial Receipt-Please retain for tax or Insurance
OP 1tRX NON-TAX ITEM 197.g0
ASHURST,JAMES (425)255-6154 #RX NON-TAX ITEM 13.26
223 B GARDEN AVE N. 12/17 2 @ 44,99
RENTON,WA 98055
DR. GRAVES,DANIEL *** TA ,00 BAL 25 64
17900 TALBOT RD S [RF] VF MO PERSONAL CHECK 250.64
RENTON,WA 98055 AskAF
Rx:6719636 May 05, 2009 Safety Cap: Yes CHANGE .00
PLAVIX 75MG TAB (B-M ) Qty:30 TAB NUMBER OF ITEMS = 4
5/05/09 13:42 1563 28 0036 7059
Ref:30000035550281 NDC:63653-1171.06 HSGI
REGENCE BS WASHINGTON Cash Price: 201.99
Amount Due: $147.40 Join the Safeway Club. Membership is
Free and Instant
1111111111 II IIIIII III IIIIIIIII [IR. REFILL YOUR PRESCRIPTIONS LET US HEAR FROM YOU!
�® �6SAffWAY.COM 1-877-723-3929 or visit SAFENAY.COM
nnnnnnnswin u
RagNiNIMPIACYtY i 3 �s�I NACY
RENTON,WA 98055 RENTON,WA 98055
#1 .3 . (425)226-0325 #1 (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] GRAVES,DANIEL
17900 TALBOT RD S [RF] 17900 TALBOT RD S [RF]
RENTON,WA 98055AskRENTON, WA 98055
Rx:6722768 May 22, 2009 Safety Cap: YesAF Rx:6710376 May 28, 2009 Safety Cap: YYesAF
FUROSEMIDE 40MG TAB (WATSKIty: 100 TAB PANTOPRAZOLE 40MG TAB (PRAS)Qty: 30 TAB
Generic for:PROTONIX 40MG TAB
Ref:30000137029211 NDC:00591-0301-10 HSGIPSH Ref:30000037461808 NDC:00008-0607-01 HSGI
REGENCE BS WASHINGTON Cash Price: 13.99 REGENCE BS WASHINGTON Cash Price: 134.49
Amount Due: $13.99 Amount Due: $102.15
II I c II II II I II(II II II III II II II REFILLTIOII III II II II IIIIII I IIII IIIILSAFE~ARCOM@SAFEYAYCOM
0000006871029002101399
p 2
SAFEWAY PHARMACY
200 SOUTH 3RD STREET
RENTON,WA 98055
#1663 1425)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. LAYMAN,SARAH [NW]
32.5 NINTH AVE
SEATTLE,WA 98104 AskAF
Rx:6726071 Jun 02, 2009 Safety Cap: Yes
HUMALOG 100U/ML INJ (LILL) Qty: 10 ML
Ref:30000037899073 NDC:00002-7510-01 HSG!
REGENCE BS WASHINGTON Cash Price: 109.98
Amount Due: $99.34
ISI I II II II I I I IIII III II I
MN
Rx�\ REFIVOW LL PRESCRIPTIONS
7540210982,4
P -3
*'" SEND CLAIM TO: City of Renton
Finance Dept.-Fire Pension
1055 South Grady Way
Renton, WA 98057
N
Y
CITY OF RENTON
FIREMEN'S PENSION BOARD
Pharmacy/Medical Claim Reimbursement Request
1) DATE '7—6. a
2) DISABILITY RETIREE'S NAME (print) 9/9A ) 5+
3) ADDRESS 1 �etn A-Veret 46S
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.)
rcq v
SA-A1-5
co
L arc
6) TOTAL AMOUNT OF CLAIM: $ 161A3
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: ya4 ei`
Note: Supporting documentation must be attached.
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 06/19/2009 REFILL STROM,KARL B 06/19/2009 REFILL
201 UNION AVE SE#142 RENTON,WA'98059 . 201 UNION AVE SE#142 RENTON,WA 98059
RX:6704612 Ref#0 QTY:90 DAW:0 DS:45 RX:6704612 Ref#0 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
80221 80221
WHI AARP Patient Pay $9.00 WHI AARP Patient Pay $9.00
i
STROM
KARL B a
0 201 UNION AVE SE#142
ILC m i RENTON,WA 98059 _
(r (425)271-8373 4 79 313 38567 6
Cl) < 06/19/2009 (425)793-7937 5.
V, Y Signature Required N RX:6704612 REF=0 OC#155 923 881 076 592 884 107 659 238 ' -
06/19/2009 12:35:02 PM WHI C
Page No : 1 of 2 TOTAL: $9.00 a
SAM'S CLUB 9015 SOUTH GRADY WAY $242.54 SAM'S CLUB 9015 SO )793-7937 UTH GRADY WAY $242.54
Pharmacy RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000
STROM,KARL B 06/19/2009 REFILL STROM,KARL B 06/19/2009 REFILL
201 UNION AVE SE#142 RENTON,WA 98059 201 UNION AVE SE#142 RENTON,WA 98059
RX:6704701 Ref#9 QTY:30 DAW:0 ; DS: 30 RX:6704701 Ref#9 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
30000179609424 30000179609424
WHI AARP/RES RX Patient Pay :. $5,00 WHI AARP/RES RX Patient Pay $5.00
Y
2
STROM
KARL B1111111 I II 0
a
0 m 201 UNION AVE SE#142
CC J RENTON,WA 98059
l� CC (425)271.8373 4 79 313 38569 0
06/19/2009 (425)793-7937 9.
Signature Required N RX:6704701 REF=9 OC#855 923 851 076 534 723 107 659 238 'f-
06/19/2009 12:35:30 PM WHI/RES
Page No : 1 of 2 TOTAL: $5.00 p
•
SAM'S CLUB (425)793-7937 ' $9.37 SAM'S CLUB (425)793-7937 $9.37
901 SOUTH GRADY WAY 901 SOUTH GRADY WAY
Pharmacy RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000
STROM,KARL B 06/19/2009 REFILL STROM,KARL B 06/19/2009 REFILL
201 UNION AVE SE#142 RENTON,WA;98059. ; , 201 UNION AVE SE#142 RENTON,WA 98059
RX:6681940 Ref#0 QTY:75 DAW:0 DS:30 RX:6681940 Ref#0 QTY:75 DAW:0 DS: 30
NDC:54458-0998-09 LISINOPRIL 5MG TAB INT NDC:54458-0998-09 ' LISINOPRIL 5MG TAB INT
MARTIN,MICHAEL M NABP:4930613 MARTIN,MICHAEL M NABP:4930613
86741 86741
WHI AARP Patient Pay $8.07 WHI AARP Patient Pay $8.87
.Y
STR
2 KARL OB O
E.'
0 m 201 UNION AVE SE#142
CC J
RENTON,WA 98059
( �j
425)271-8373 4 79313 38568 3
Cl) Y 06/19/2009 (425)793-7937 :::
V/ Signature Required N RX:6681940 REF=0 OC#055 923 836 876 592 884 107 659 238 '8
06/19/2009 12:35:14 PM WHI
Page No : 1 of 2 TOTAL: $8.37 a
Pilde S
4,r
SAM'S CLUB (425)793-7937
901 SOUTH GRADY WAY $8.00 SAM'S CLUB 90 SOUTH GRADY WAY $5.00
Pharmacy RENTON,WA 98055-0000 • Pharmacy RENTON,WA 98055-0000
STROM,KARL B 06/19/2009 REFILL STROM,KARL B 06/19/2009 REFILL
201 UNION AVE SE#142 RENTON,WA 98059 • 201 UNION AVE SE#142 RENTON,WA 98059
RX:6697947 Ref#0 QTY:60 DAW:0 DS: 30 RX:6697947 Ref#0 . 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
80181 . 80181
Will AARP Patient Pay $4.59 WHI AARP Patient Pay $4.59
Y
STROM
KARL B ii.
0 m 201 UNION AVE SE#142
CC J RENTON,WA 98059
1i^ Cr 06/19/2009 (425))7 3-793 3 4 79313 38566 9
V' (425 7 71-837
Signature Required N RX:6697947 REF=0 OC#655 923 869176 592 384107 659 238 ..
06/19/2009 12:34:44 PM WHI o
Page No : 1 TOTAL: $4.59 a
SAM'S CLUB (425)793-7937 $4.00 SAM'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 06/20/2009 REFILL STROM,KARL B 06/20/2009 REFILL
201 UNION AVE SE#142 RENTON,WA 98059 201 UNION AVE SE#142 RENTON,WA 98059
RX:6702397 Ref#3 QTY: 30 DAW: 0 DS: 30 RX: 6702397 Ref#3 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
54511 54511
WHI AARP Patient Pay $3.00 WHI AARP Patient Pay $3.00
2 STROM L
KARL B 4-
0 m 201 UNION AVE SE#142 Cl)
CC RENTON,WA 98059 1`
ri (425)271-8373 4 79313 38959 9
Q 06/20/2009 (425)793-7937
I Y Signature Required N RX:6702397 REF=3 OC#555 923 871 076 592 388 107 659 238 21
06/20/2009 05:30:18 PM WHI
Page No : 1 of 3 TOTAL: $3.00 d
Database Edition:92.Information Expires 07/16/2009
SAM'S CLUB (425)793-7937 $10.00 SAM'S CLUB (425)793-7937 $10.00
901 WAY Pharmacy90
Pharmacy RENTONSOUTHWAGRADY 98055-0000 RENTON1SOUTHWAGRADY 98055-W AY
WAY
STROM,KARL B 06/29/2009 REFILL STROM,KARL B 06/29/2009 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
36971 36971
WHI AARP Patient Pay $9.00 WHI AARP Patient Pay $9.00
Y
2 STROM
KARL B III0e
a
0 m 201 UNION AVE SE#142
CC RENTON,WA 98059INI
--I (425)271-8373
4 79313 32168 1
V/ Q 06/29/2009 (425)793-7937 ..
Y Signature Required N RX:6692403 REF#P OC#155 923 881 076 592 884107 659 238 '8
06/29/2009 09:44:08 AM WHI
Page No : 1 of 2 TOTAL: $9.00 ff-
l'460
SAM'S CLUB (425)793-7937 4„ $37.78 SAM'S CLUB (425)7 7 $37.78
901 SOUTH GRADY WAY 901 SOU�GRADY WAY
Pharmacy RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000
STROM,KARL B 07/01/2009 REFILL STROM,KARL B 07/01/2009 REFILL
201 UNION AVE SE#142 RENTON,WA 98059 201 UNION AVE SE#142 RENTON,WA 98059
RX:4416064 Ref# 1 QTY: 180 DAW:0 DS:30 RX:4416064 Ref# 1 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
11621 11621
WHI AARP Patient Pay $16.97 WHI AARP Patient Pay $16.97
� IIIII
B
0Mm 201 UNION AVE SE 4142
CC I RENTON,WA 98059III
N (425) 373 4 79313 415 66 3
07/01/2009 (425)793-793-7 937 �.
Signature Required N RX:4416064 REF=1 OC#455 923 494 876 592 384 107 659 238
07/01/2009 12:50:25 PM WHl O
Page No : 1 of 2 TOTAL: $16.97 a.
Department of Veterans Affairs
1660 S COLOMBIAN WAY STATEMENT OF MEDICAL CARE COST RECOVERY ACCOUNT ACTIVITY
SEATTLE WA 98108-1532
NAME OF FACILITY
AGENT CASHIER (136MCCR) VA PUGET SOUND HEALTH CARE SYSTEM (663)
FOR QUESTIONS ABOUT YOUR ACCOUNT, PLEASE PHONE THE
BELOW NO. 1-866-290-4618 -.
11,1nduli11un1111 11��������������i���u������n��,� For written inquiries concerning your account please send them
to the MCCR or Revenue Office at the facility address above.
*060718 - 062409 060718
KARL B STROM JR Payments received after 06/20/2009 will be on
201 UNION AVE SE UNIT 142 your next statement.
RENTON WA 98059-5177
SEATTLE MCCR WILL NO LONGER ACCEPT WALK-IN'S, FOR HELP CALL 1-866-290-4618
itient Name: KARL B STROM JR Account No: 663-000000-7237347-STROM Stmt Date: 06/24/2009
: ... ;FR: .
�tRl�lS��'fE.f)N;PC3 `�f3:.:,.: >:`` :< . :: <.:>: :>:<_`< ,:: f2r*S�#:..�`�1�E.::.....::...::. . .... .:.:::..:... .. A... :: .:T. ..:.: ..,. g.
04/04/2009 PAYMENT (04/03/2009) 48.00- 663-K903L3U
06/03/2009 COPAY RX:4245408B FD:05/29/2009 24.00 663-K905M85
DRUG:AMIODARONE HCL (PACERONE) 200MG TAB
DAYS:90 QTY:90 PHY:WICHER,JOHN B CHG:$24.00
‘ °Y
V ILA 3,--D2-1/
SUMMARY OF P fOU4 34ANC l'AW SRg::.:.i : NSWARa.<
NBALA:.;N.I ;MONTHLY ACTIVITY . : : ; "" , » :
48.00 48.00- 24.00 24.00
PLEASE DETACH THIS COUPON BELOW AND RETURN WITH PAYMENT. DO NOT INCLUDE ANY CORRESPONDENCE WITH PAYMENT. 'N