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Home My WebLink AboutFinal Agenda Packet Nowr..r( CITY OF RENTON FIREMEN'S PENSION BOARD Regular Meeting 7th Floor-Mayor's Conference Room Thursday, December 18, 2008 2:00 P.M. 1. CALL TO ORDER 2. APPROVAL OF MINUTES OF NOVEMBER 20, 2008 3. CORRESPONDENCE Memo - Barilleaux Term Expiration 4. MONTHLY STATEMENT TO NOVEMBER 30, 2008 5. MONTHLY BILLS AND PENSION PAYMENTS 6. UNFINISHED BUSINESS 7. NEW BUSINESS 8. ADJOURNMENT %we MINUTES °"t. FIREMEN'S PENSION BOARD CITY OF RENTON November 20, 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 Acting Chairman Don Persson at 2:04 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 present: Jill Masunaga, Finance Representative. MINUTES APPROVAL MOVED BY BARILLEAUX, SECONDED BY PHILLIPS, THE PENSION BOARD APPROVE THE MINUTES OF THE OCTOBER 16, 2008,MEETING. CARRIED. MONTHLY STATEMENT The financial report as of October 31, 2008, was reviewed. Total cash/investment balance was $4,440,521.13. MONTHLY BILLS AND PENSION PAYMENTS MOVED BY PHILLIPS, SECONDED BY BARILLEAUX, THE BOARD APPROVE THE PENSION/MEDICAL PAYMENTS FOR NOVEMBER 2008,IN THE TOTAL AMOUNT OF $42,562.45 TO BE PAID FROM THE FIREMEN'S PENSION FUND. CARRIED. Jill Masunago requested confirmation of the prescription drug expense limits as those of Mr. Charles Goodwin have exceeded$2,000. The Board clarified that the$2,000 annual limit is only on non-disability prescription expenses. NEW BUSINESS It was announced that retiree Patrick Walsh passed away November 19, 2008, and that Mr. Walsh's wife is deceased. In response to Mr. Persson's inquiry, it was confirmed that Mr. Walsh's Firemen's pension payment would be paid through the month of November. MOVED BY BARILLEAUX, SECONDED BY PHILLIPS, APPROVE FOR PAYMENT IN NOVEMBER THE$500 DEATH BENEFIT TO THE FAMILY OF PATRICK WALSH. CARRIED. MOVED BY PHILLIPS, SECONDED BY BARILLEAUX TO HAVE THE BOARD SECRETARY OBTAIN A CITY ATTORNEY OPINION ON WHETHER THE DEATH BENEFIT AMOUNT CAN BE INCREASED BEYOND THE $500 AMOUNT SET BY RCW 41.18.140. CARRIED ADJOURNMENT MOVED BY BARILLEAUX, SECONDED BY PHILLIPS,THE MEETING OF THE FIREMEN'S PENSION BOARD BE ADJOURNED. CARRIED. Time: 2:17 p.m. 6614442-e--4 tda-ei. Bonnie I. Walton, City Clerk Member and Secretary,Firemen's Pension Board No vime (cYo ADMINISTRATIVE, JUDICIAL, AND 4 4=, LEGAL SERVICES DEPARTMENT Office of the City Clerk MEMORANDUM DATE: November 20, 2008 TO: I. David Daniels, Fire Chief FROM: 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, 2008. 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, 2009 to December 31, 2010. Thank you for your assistance. I can be reached at x6502 if you need additional information. cc: Bob Van Horne, Deputy Fire Chief Firemen's Pension Board Members fir' ,.,Me CITY OF RENTON - FIREMEN'S PENSION FUND CASH & INVESTMENT ACTIVITY REPORT AS OF NOVEMBER 30, 2008 Fireman's Pension Fund Comparison of Cash and Investment Activity 6 ■2008 0 2007 5 �o tilitilift c 4 I - G c 3 o E 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 $4,440,521.13 $4,694,232.48 $4,203,347 $4,403,373.58 $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 (88,764.13) 16,933.76 200,000 1,467.05 389,226.86 175,000 DISBURSEMENTS: Fire Pension 41,952.86 471,712.94 552,400 34,695.56 427,011.96 463,500 Fire Pension Medical 1,109.59 8,045.39 20,000 784.50 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 9,119.00 9,948 686.00 8,226.00 8,226 ENDING CASH/INV BALANCE $4,307,865.55 $4,307,865.55 $3,895,540 S4,388,674.57 $4,694,232.48 $4,203,347 CURRENT PREVIOUS LAST YEAR LAST YEAR ACTIVITY: MONTH MONTH CURR MO PREV MO CASH $546,745.98 $590,077.75 $162,962.30 $197,661.31 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 0.00 89,323.81 TOTAL CASH AND INVESTMENTS $4,307,865.55 $4,440,521.13 $4,368,674.57 $4,403,373.58 The State Investment Pool interest 2.1903% 2.4652% 4.6985% 4.9108% H:\FINANCE\FINPLAN\FIREPEN\1_Fire_Pension_2008.xls\Nov08 Page 1 12/12/2008 %rniso *woo FIREMEN'S PENSION BOARD PENSION/MEDICAL PAYMENTS FOR DECEMBER, 2008 ANKENY, Charlie (Captain) $90.81 90.81 ASHURST, James (Assistant Chief) $4,569.00 536.29 5,105.29 ' 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) $4,010.50 845.26 4,855.76 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 69.45 3,208.95- 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 76.22 3,101.22 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 WEISS, Larry(Battalion Chief) $1,354.42 1,354.42 WILLIAMS, Alta (Widow) - - WOOTENMarilyn E. (Widow) $200.10 200.10 F if4174ta, j er1ses" elisiotilMedrO il' 0 > 4x; 9 89 .7,0V$ 2,74.- 1#110407;7011. Prior Year Pension/Medical Payments: Total Pension Payments for December, 2007 34,695.56 Total Medical Bills Reimbursed in December, 2007 406.24 Total Expenses: Medical/Pension 35,101.80 4_SUMMARY 2008.XLS 12/12/2008 . tolo, value FIREMEN'S PENSION BOARD MEDICAL BILLS TO BE REIMBURSED IN DECEMBER, 2008 PAYMENT 77P-.001M4r;.:AaiftiVflMi%'YPtz*.4F06.01001141,06:10: .�� ` 2 James Ashurst Safeway 10/30/08 4.95 2 James Ashurst Safeway 11/03/08 141.80 2 James Ashurst Safeway 11/03/08 192.86 2 James Ashurst Safeway 11/05/08 102.15 2 James Ashurst Safeway 11/23/08 11.99 2 James Ashurst Safeway 11/23/08 82.54 536.29 4 Charles Goodwin Bartell Drugs 10/24/08 182.27 4 Charles Goodwin Bartell.Drugs 10/25/08 9.80 4 Charles Goodwin Bartell Drugs 10/25/08 49.59 4 Charles Goodwin Bartell Drugs 10/27/08 361.76 845.26 Jack Haworth 0.00 7 John Parks Olympic Drug 10/27/08 2.31 7 John Parks Olympic Drug 10/27/08 14.01 7 John Parks Olympic Drug 10/27/08 6.28 7 John Parks Olympic Drug 11/02/08 46.85 `' 69.45 9 Karl Strom Sam's Club 11/14/08 4.41 9 Karl Strom Sam's Club 11/14/08 9.00 9 Karl Strom Sam's Club 11/14/08 3.00 10 Karl Strom Sam's Club 11/14/08 12.48 10 Karl Strom Sam's Club 11/14/08 7.33 10 Karl Strom Sam's Club 11/17/08 9.00 11 Karl Strom Sam's Club 11/25/08 7.00 11 Karl Strom Department of Veterans Affairs 11/18/08 24.00 76.22 ,��0' ��i`"��:,:'d��V ,,;:': : ��.AW,,,� s0'qPv:"K-.; � Nme SEND CLAIM TO: r.r City of Renton Finance Dept.-Fire Pension 1055 South Grady Way Renton, WA 98057 CJS(cY O1 CITY OF RENTON FIREMEN'S PENSION BOARD Pharmacy/Medical Claim Reimbursement Request 1) DATE NOVEMBER 28 2008 2) DISABILITY RETIREE'S NAME (print) JAMES F. ASHURST 3) ADDRESS 223 GARDEN AVE_ N. #B REOTON WA. 98057 .4) DISABILITY AT TIME OF RETIREMENT HYPERTFIVS TON H_R_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 36_ 79 Amount of total claim (above) that is related to the Retirement Disability: $ 448. 80 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 ofmy knowledge_and that any charges other Lhan 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. 1ACY �", , � �CY RENTON,WA 98055 RENTON,WA 98055 # (425)226-0325 # (425)226-0325 Official Receipt- Please retain for tax or insurance Official Receipt- Please retain for tax or insurance ,31 .} ES (425)255-61 54 ASHURST,JAMES (425)255-61 54 R y.1 AVE N. 12/17 223 B GARDEN AVE N. 1 2/1 7 RENTON,WA 98055 RENTON,WA 98055 DR. CHANG,WALLACE H J MD [NW] DR.7900 GRAVES, DANIEL S [RF] 17930 TALBOT RD SOUTH RENTON,WA RENTON,WA 98055 Ask Rx:6715469 Oct 30, 2008 Safety Cap: YesAF Rx:6710376 Nov 05, 2008 Safety Cap: YesAF CEPHALEXIN 250MG CAP (TEVA)Qty: 12 CAP PANTOPRAZOLE 40MG TAB (PRAS) Qty:30 TAB Generic for:KEFLEX 250MG CAP Generic for:PROTONIX 40MG TAB Ref:A5087042488121 NDC:00093.3145.05 HSGIPSH Ref:A7087100325581 NBC:00008.0607.01 HSG! REGENCE BLUESHIELD WASH Cash Price: 9.99 REGENCE BLUESHIELD WASH Cash Price: 134.49 Amount Due: $4.95 Amount Due: $102.15 HI II II IIIA IIIIIIIII IIIIIIII (Rx REFILL YOUR PRESCRIPTIONS H II II(III II IIIIII II 11111111 EFS SYOUR PRESCRIPTIONS (�,� SAfEWAY.COM 29002100495 0 00000068710 ooso �HRPHAMACYMRWA RACYCs) zu3D STREET irs) RENTON,WA 98055 RENTON,WA 98055 (425)226-0325 #1563 (425)226-0325 Official Receipt- PFease retain for tax or insurance Official Receipt- Please retain for tax or insurance ASHURST,JAMES (425)255-61 54 ASHURST,JAMES (425)255-6154 223 B GARDEN AVE N. 1 2/1 7 223 B GARDEN AVE N. 12/17 RENTON,WA 98055 RENTON,WA 98055 DR. GRAVES,DANIELDR. GRAVES,DANIEL [RF] 17900 TALBOT RD S, STE 101 [RF] 17900 TALBOT RD S RENTON,WA 98055 RENTON,WA 98055 AskAF Rx:6702058 Nov 03, 2008 Safety Cap: YesAF Rx:6707635 Nov 23, 2008 Safety Cap: Yes PLAVIX 75MG TAB (B M ) Qty:30 TAB FUROSEMIDE 40MG TAB (WATS)Qty: 100 TAB Generic for:FUROSEMIDE 40MG TAB BBAIPPN Ref:A2087283558061 NBC:00591-0301-10 KT/ Ref:E1 N708 NBC:S 63653-1171-06REGENCE BLUESHIELD WASH Cash Price: 11.99 REGENCE BLUESHIELD WASH Cash Price: 194.99 Amount Due: $11.99 Amount Due: $141.80 II II II II II II 11181111111111H Rx x REFILL YOUR PRESCRIPTIONS HWIIIIUHIII R x REFIL SAfEWAYCOM TIONS [�,�, @ SAfEWAY.COM 00000068710 0 29002101199 SAF�V1IA.y s YYI JlAfJACYCS) 2b��oU�H�RDP 1 CY 1.50 RENTON,WA 98055 RENTON,WA 98055 (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.STE 101 17900 TALBOT RD S RENTON,WA 98055 RENTON,WA 98055 AskAF AskAF Rx:6706816 Nov 23, 2008 Safety Cap: Yes Rx:6701701 Nov 03, 2008 Safety Cap: YessHUMULIN N VIA (EIEC) Qty: 20 ML LIPITOR 40MG TAB (PFIZ) Qty:50 TAB Ref:A0087084110801 NBC:00071.0157.23 BBAIPPN Ref:A8087281914961 NDC:00002-8315-01 KT( REGENCE BLUESHIELD WASH Cash Price: 240.49 REGENCE BLUESHIELD WASH Cash Price: 89.98 Amount Due: $192.86 Amount Due: $82.54 OIIIIIIIIIIIIIIII flIIIIIIIIII REFILL YOUR SAFEwaRrcOMT/ONS 1IIIIIIIIIIIIMIIIIIIIIiit Ci_ REF" YOEWAYCOMUR TONS 00000068710 29002108254 Rx --- ----..._.._ _. --•--... ' -(;T27UM- SENDCLAIMTO: .iirCity of Renton Finance Dept.-Fire Pension 1055 South Grady Way Renton, WA 98057 +olem YP IS CITY OF RENTON FIREMEN'S PENSION BOARD Pharmacy/Medical Claim Reimbursement Request 1) DATE /2/0h f 2) DISABILITY RETIREE'S NAME (print) Cie/7/X'l'e'S /i- C ®/�&> Al 3) ADDRESS A1/1/ 7004p.de E �. c /6 Welfind t QUA /p_c-- 4) DISABILITY AT TIME OF RETIREMENT Ab-724.1 allot/of • ,y f / • 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.) /%i .1 6) TOTAL AMOUNT OF CLAIM( 0 -T c. o� 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 from the Renton Fire Department. Signature: giZetrr-6 a Note: Supporting documentation must be attached. 16e63 , /,3/76/D Y '---7-70 : aL.,,,-.Lii-,Lzi N..0, _ „:„.„„: 4,,,,,,, ,,,/,‘, c ,,, , A- , -eo Dkil Ai - 1 BARTELL DRUGS I BARTELL DRUG S .. Washington's Own Drugstoress�� Va,htn n'sE DR.gstarer RX# 45-444249 E DR. KATO,GARY H. RX# 45- 4593 E DR. LORCH,GERALD DATE: 10/24/08 N (425)251-5110 10/25/08 R (425)255-9310 NAME: CHARLES GOODWIN NAME: CHARLES GOODWIN 1414 MONROE AVE NE#306 1414 MONROE AVE NE#306 AGGRENOX CAP 200/25 AMLODIPINE 5MG TABLET(*LUP) 00597-0001-60 2008457937609 68180-0751-09 2785296494659 REFILL 3 QUANTITY 30.00 REFILL 5 QUANTITY 60.00 BARTELL DRUGS PRICE= $195.99 BARTELL DRUGS PRICE= $54.49 ii '7q, WITH SR THE AMOUNT DUE:$182.27 if N-0)7 WITH SR THE AMOUNT DUE 449.59 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 REFILLS 24-48 HOURS IN ADVANCE LL BARTELL DRUGS I BARTELL DRUGS enwienWashington's Own Drugstores�� ..... .•Wnshington'sOwnDrugstores----� R" 45-431280 E DR. GRIFFITH,ALIDA "I 45-454813 E DR. LORCH,GERALD DATE: 10/27/08 R (425)899-3123 DATE: 10/25/08 R (425)251-5110 NAME: CHARLES GOODWIN NAME: CHARLES GOODWIN 1414 MONROE AVE NE#306 1414 MONROE AVE NE#306 S OL 100MG TABLET(*PA CARBIDOPA/LEVODOPA 25MG/100M 2785296684659 00093-0293-01 3-0101 2798789004659 498 ---- + b REFILL 2 QUANTITY 540.00 3�( ' REFILL 4 QUANTITY 30.00 lI BARTELL DRUGS PRICE= $10.99 "� 9 BARTELL DRUGS PRICE= $388.99 WITH SR THE AMOUNT DUE'49.89 WITH SR THE AMOUNT DUE:$361.76 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 YOURi REFILLS 24-48 HOURS IN ADVANCE REFILLS 24-48 HOURS IN ADVANCE Nil i "PlLf- b i-L I' %y/Q/of 1U0 ,...0 AtiAJIA-cIAF ode., Obli-bc , ;,(4_ „d_Deidid- , 4„.A.A.L.; BARTELL DRUGS I BARTELL DRUGS ---�w.hinglat'.Oran, ........n �WawhingtonLOwn Drugstores ... .... RX# 45- 444249 E D>KATO,GARY H. RX# 45-459328 E DR. LORCH,GERALD DATE: 11/29/08 R '(425)255-9310 DATE: 11/21/08 R (425)251-5110 NAME: CHARLES GOODWIN NAME: CHARLES GOODWIN 1414 MONROE AVE NE#306 1414 MONROE AVE NE#306 AGGRENOX CAP 200/25 AMLODIPINE 5MG TABLET(*LUP) 00597-0001-60 3099124484659 68180-0751-09 3170345024659 ---- REFILL 2 QUANTITY 30.00 REFILL 4 QUANTITY 60.00 BARTELL DRUGS PRICE= $195.99 �J� 0 `� ,Yf )Q a ." BARTELL DRUGS PRICE= $54.49 ,/�0. WITH SR THE AMOUNT DUE$182.27 WITH SR THE AMOUNT DUE=$49.59 BARTELL DRUGS#45 BARTELL DRUGS#45 (425)793-1015 �� a (425)793-1015 4700 NE 4TH STREET ° 4700 NE 4TH STREET I �' 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 YOURL REFILLS 24-48 HOURS IN ADVANCE I REFILLS 24-48 HOURS IN ADVANCE , BARTELL DRUGS ..m.. ..Waahiagton'.Own Drngdwnann.mwmwm RX# 45- 454813 E DR. LORCH,GERALD DATE: 11/29/08 R —1425)251-5110 NAME: CHARLES GOODWIN 1414 MONROE AVE NE#306 ALLO- - - ,OL 100MG TABLET(*PA 612-- =--� 498:4-0602-10 -- 3170345304659 1 REFILL 3 QUANTITY 30.00 ! ' BARTELL DRUGS PRICE= $10.99 e 0� / / -17`�j, - Stf2 (.0 WITH SR THE AMOUNT DUE 49.89 ,se / / (/�( 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 I Ir SEND CLAIM TO: s+►` City of Renton Finance Dept.-Fire Pension 1055 South Grady Way Renton, WA 98057 ANT0) CITY OF RENTON FIREMEN'S PENSION BOARD Pharmacy/Medical Claim Reimbursement Request 1) DATE 9_Q4-i la": vZ6'o 6 2) DISABILITY RETIREE'S NAME (print)teih/ 1---r P-.i s 3) ADDRESS 035 r' ,•721A ye.. *10 9 Lai y t evv/ 1/ri (16'6 32.. U 4) DISABILITY AT TIM OF RETIREMENT -� a h R t o prs-6h34 - A *Id- 4- r7 P7',abf ' 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.) l ' i ` 4 ' If I u A i o' I . 0 '77n.3' 6) TOTAL AMOUNT OF CLAIM: $ 9, ? Amount of total claim (above) that is related to the Retirement Disability: $ C-1/9-5 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. 4111 , � i Signature: ,a7�, A4 Note: Suppor ' documentation must be attached. IOW ‘4111110 412to'`eaMaPheIC OD RURECEIPT 1244 15th Ave.,Longview,WA 98632 Ph.(360)423-3360 SAVEFOR INSURANCE marC831450OR TAX RECORDS 10.27.08 CAN:A1087019547491or1335. JOHNDD AVE#109 LONGVIEW,WA 98632 (360) 577-6684 ZOLPIDEM TAB 10MG *** $ #30 NDC: 60505-2605-08 DR. RICHARDS,JOHN E ZHA COPAY: $2.31 111011111111111111111113111111 III Price J YWAR OD RUG RECEIPT 124415th Ave.,Longview,WA 98632 Ph.(360)423-3360 SAVE FOR INSURANCE OR TAX RECORDS Rx# 831413 For. JOHN PARKS 10-27-08 CAN:81087013224251 1335 3RD AVE#109 LONGVIEW,WA 98632 (360) 577-6684 MIRTAZAPINE SOLTAB 45MG #30 NDC: 65862-00234)6 DR. RICHARDS,JOHN E ZHA COPAY: $14.01 II0II II I IIII U0I II III 0 001 II OOMOI II 100101011111 1111 Price Value n the smil,g'O' '12E ' PIC DRUG RECEIPT 1244 15th Ave.,Longview,WA 98632 Ph.(360)423-3360 SAOR FOR INSURANCE OR TAX RECORDS Ra C831415 For. JOHN PARKS 10-27.08 CRN:A8087011557181 1335 3RD AVE#109 LONGVIEW,WA 98632 (360) 577-6684 ALPRAZOLAM 0.5MG TAB *** #60 NDC: 59762-3720-03 DR. RICHARDS,JOHN E ZHA COPAY: $6.28 11111 00111111 1111111 II I III IIIII III Ill II III 111111 II Price Value at emiling'0' �'YII'IPIC DRUG RECEIPT 1244,15th Ave.,Longview,WA 98632 Ph.(360)423-3360 SAOR FOR INSURANCE OR TAX RECORDS Fla 831449 For JOHN PARKS 11-02-08 CAN:A4087072222761 1335 3RD AVE#109 LONGVIEW,WA 98632 (360) 577-6684 OMEPRAZOLE TAB 20MG(OTC) 90 NDC: 5.0837.06 RICHARDS,JOHN E DR. ZHA COPAY: $46.85 111111111111 III I IllIllIlI it 011111001111111111 Price "''"" SENDCLAIMTO: ""''City of Renton Finance Dept.-Fire Pension 1055 South Grady Way Renton, WA 98057 8 R) CITY OF RENTON FIREMEN'S PENSION BOARD Pharmacy/Medical Claim Reimbursement Request 1) DATE - /- 4 3 2) DISABILITY RETIREE'S NAME (print) KA- / 75 S`/-E0"t i Karl Strom 3) ADDRESS 201 Union Ave.SE#142 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.) ti A 7 J O L 0-11• Q° 5i 6) TOTAL AMOUNT OF CLAIM: $ Amount of total claim (above) that is related to the Retirement Disability: $ 7 , 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. Now erre TAM'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 11/14/2008 REFILL STROM,KARL B 11/14/2008 REFILL 15616 SE 143RD RENTON,WA 98055 15616 SE 143RD RENTON,WA 98055 RX:6678271 Ref# 1 QTY:30 DAW:0 DS: 60 RX:6678271 Ref# 1 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 83571 83571 WHI AARP Patient Pay WHI AARP y $4.41 ✓ $4.41 Patient Pa 2 STROM OM m 11566SE1143RD B IIIII o Q. CC J� RENTON,WA 98055III (425)271.8373 4 79312 86354 0 0 11/14/2008 (425)793-7937 Signature Required N RX:6678271 REF=1 OC#655 923 865 776 592 884 107 659 238 C 11/14/2008 11:47:16 AM WHI Page No : 1 of 2 TOTAL: $4.41 a • !AM'S CLUB (425)793-7937 $10.00 SAM'SCLUB (425)793-7937 901 SOUTH GRADY WAY 901 SOUTH GRADY WAY $10.00 Pharmacy ST STROM,KARL B 11/14/2008 REFILL RENTON,WA 98055 0000 PS'TROM KARL RENTON,WAarmacy 98055-0000 11/14/2008 REFILL 15616 SE 143RD RENTON,WA 98055 15616 SE 143RD RENTON,WA 98055 RX:6683460 Ref# 1 QTY:90 DAW:0 DS:30 RX:6683460 Ref# 1 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 83541 83541 WHI AARP Patient Pay $9.00 WHI AARP Patient Pay $9.00 3,- 2 STROM 0�+ CO 156161SE 1143RD a CC RENTON,WA 98055 (425)271-8373 4 79312 86353 3 11/14/2008 (425)793-7937 Signature Required N RX:6683460 REF=1 OC#155 923 881 076 592 884 107 659 238 11/14/2008 11:47:09 AM WHI C Page No : 1 of 2 TOTAL: $9.00 p • 1AM'S CLUB (425)793-7937 $10.78 SAM'S CLUB (425)793-7937 $10.78 901 SOUTH GRADY WAY 901 SOUTH GRADY WAY Pharmacy BRL B RENTON,WA 98055-0000 11/14/2008 REFILL STROM,KAENTON,WA 9e055-0000 11/14/2008 REFILL 15616 SE 143RD RENTON,WA 98055 15616 SE 143RD RENTON,WA 98055 RX:6672060 Ref#6 QTY:60 DAW:0 DS:30 RX:6672060 Ref#6 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 83531 83531 WHI AARP Patient Pay $3.00 WHI AARP Patient Pay $3.00 iiir- 2 STROM O�r m 1511616 SEB143RD111 d CC J RENTON,WA 980551111III 5 CC (425)271-8373 Q 11/14/2008 (425)793-7937 4 79312 86352 6 Signature Required N RX:6672060 REF=6 OC#355 923 871 076 592 884 107 659 238 :. 11/14/2008 11:47:04 AM WHI Q Page No : 1 of 2 TOTAL: $3.00 p 14 : 1 IAM'S CLUB (425)793-7937 $25.46 SAM'S CLUB (425)793-7937 901 SOUTH GRADY WAY $25.46 901 SOUTH GRADY WAY Pharmacy RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000 STROM,KARL B 11/14/2008 REFILL STROM,KARL B 11/14/2008 REFILL 15616 SE 143RD RENTON,WA 98055 15616 SE 143RD RENTON,WA 98055 RX:4412944 Ref#0 QTY: 120 DAW:0 DS:30 RX:4412944 Ref#0 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 83501 83501 WHI AARP Patient Pay $12.48 WHI AARP Patient Pay $12.48 5"- 2 2 STROM a 0 m KARL B111 11 1 1 1111 — 15616 SE 143RD _ CC —I RENTON,WA 98055 CC (425)271-8373 4 79312 86351 9 0 11/14/2008 (425)793-7937 Signature Required N RX:4412944 REF=0 OC#155 923 405 476 592 384 107 659 238 L. 11/14/2008 11:46:41 AM WHI C Page No : 1 of 2 TOTAL: $12.48 p` IAM'S CLUB 9015 SOUTH GRADY WAY)793-7937 $9'37 SAM'S CLUB 9015 SO )793-7937 UTH GRADY WAY $9.37 Pharmacy RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000 STROM,KARL B 11/14/2008 REFILL STROM,KARL B 11/14/2008 REFILL 15616 SE 143RD RENTON,WA 98055 15616 SE 143RD RENTON,WA 98055 RX:6681940 Ref# 1 QTY:75 DAW:0 DS:30 RX:6681940 Ref# 1 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 85101 85101 WHI AARP Patient Pay $7,33 WHI AARP Patient Pay $7,33 7 STROM a 2 KARL B111 11 1 1 n 0 m 15616 SE 143RD CC J RENTON,WA 98055 CC (425)271-8373 4 79312 86355 7 11/14/2008 (425)793-7937 w# Signature Required N RX:6681940 REF=1 OC#855 923 826 576 592 884 107 659 238 it 11/14/2008 11:47:20 AM WHI C Page No : 1 of 2 TOTAL: $7.33 p VAM'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 11/17/2008 NEW STROM,KARL B 11/17/2008 NEW 15616 SE 143RD RENTON,WA 98055 15616 SE 143RD RENTON,WA 98055 RX:6692403 Ref#P QTY;90 DAW;0 DS;90 RX;6692403 Ref#P CITY: 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 24301 24301 WHI AARP Patient Pay $9.00 WHI AARP Patient Pay $9,00 0 STROM 0 m KARL B n^ 15616 SE 143RD §.C' _I RENTON,WA 98055 (425)271-8373 . 11/17/2008 (425)793-7937 4 79312 86349 6 Signature Required N RX:6692403 REF#P OC#155 923 881 076 592 884 107 659 238 r. 11/17/2008 11:40:05 AM WHI 0 Page No : 1 TOTAL: $9.00 a Department of Vete, is Affairs 1660 S COLUMBIAN WAY SEATTLE WA 98108-1532 STATEMENT OF MEDICAL CARE COST RECOVERY ACCOUNT ACTIVITY 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 For written inquiries concerning your account please send them .- 05652? - 112408 to the MCCR or Revenue Office at the facility address above. — KARL B STROM JR Payments received after 11/20/2008 will be on 201 UNION AVE SE UNIT 142 your next statement. RENTON WA 98059-5177 CALL WITH YOUR HEALTH INSURANCE INFORMATION • andommi itient Name: KARL B STROM JR Account No: 663-000000-7237347-STROM Stmt Date: 11/24/2008 .- 10/08/2008 PAYMENT (10/07/2008) 48.00- 663-K807K7E 11/18/2008 COPAY RX:4245408B FD: 11/28/2008 24.00 663-K9017V7 DRUG:AMIODARONE HCL (PACERONE) 200MG TAB DAYS:90 QTY:90 PHY:WICHER,JOHN B CHG:$24.00 I SAM'S CLUB (425)793-7937 $8.00 SAM'S CLUB (425)793-7937 $8.00 901 SOUTH GRADY WAY 901 SOUTH GRADY WAY Pharmacy RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000 STROM,KARL B 11/25/2008 REFILL STROM,KARL B 11/25/2008 REFILL 15616 SE 143RD RENTON,WA 98055 15616 SE 143RD RENTON,WA 98055 RX:6683461 Ref# 1 QTY:60 DAW:0 DS:30 RX:6683461 Ref#1 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 16311 16311 WHI AARP Patient Pay $7.00 WHI AARP Patient Pay $7.00 K ARLB III 15616 SE 143RD 0 m RENTON,WA 98055 CC (425)271-8373 4 79312 88872 7 1I-- < 11/25/2008 (425)793.7937 VJ Signature Required N RX:6683461 REF=1 OC#555 923 821 076 592 384 107 659 238 11/25/2008 12:17:13 PM WHI C Page No : 1 TOTAL: $7.00 a P