HomeMy WebLinkAboutFinal Agenda Packet No
CITY OF RENTON
FIREMEN'S PENSION BOARD
Regular Meeting
7th Floor-Mayor's Conference Room
Thursday, June 19, 2008
2:00 P.M.
1. CALL TO ORDER
2. APPROVAL OF MINUTES OF MAY 15, 2008
3. CORRESPONDENCE
a.) Fire Insurance Premiums Revenue Distribution
b.) Cost of Living Increase- Widows
4. MONTHLY STATEMENT TO MAY 31, 2008
5. MONTHLY BILLS AND PENSION PAYMENTS
6. UNFINISHED BUSINESS
7. NEW BUSINESS
8. ADJOURNMENT
Noir *are
MINUTES
FIREMEN'S PENSION BOARD
CITY OF RENTON
May 15, 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 Mayor Denis Law at
2:05 p.m. in the Mayor's Conference room, 7th floor of Renton City Hall. In attendance were
Board members Denis Law, Don Persson, Ray Barilleaux, and Bonnie Walton. Also in
attendance was Jill Masunaga, Finance Department representative.
MINUTES APPROVAL
MOVED BY BARALLEAUX, SECONDED BY PERSSON, THE PENSION BOARD
APPROVE THE MINUTES OF THE APRIL 17, 2008, MEETING. CARRIED.
CORRESPONDENCE
A certification letter sent by Board Secretary Walton to the Office of the State Treasurer was
reviewed. For 2008 Fire Insurance Premium distribution purposes, 103 paid firemen were
employed in the City of Renton Fire Department as of December 31, 2007. Also reviewed was
the letter sent to the five Fire Pension retirees notifying them of the expanded prescription drug
benefits approved by the Board on March 20, 2008. The retirees were informed that they may
now submit any and all prescription drug expenses for reimbursement from the Firemen's
Pension Fund, provided there is no other reimbursement source or insurance coverage.
MONTHLY STATEMENT
The financial report as of April 25, 2008, was reviewed. Total cash/investment balance was
$4,514,867.86.
MONTHLY BILLS AND PENSION PAYMENTS
MOVED BY BARILLEAUX, SECONDED BY PERSSON, THE BOARD APPROVE THE
PENSION/MEDICAL PAYMENTS FOR MAY 2008, IN THE TOTAL AMOUNT OF
$41,668.23 TO BE PAID FROM THE FIREMEN'S PENSION FUND. CARRIED.
ADJOURNMENT
MOVED BY PERSSON, SECONDED BY BARILLEAUX, THE MEETING OF THE
FIREMEN'S PENSION BOARD BE ADJOURNED. CARRIED. Time: 2:10 p.m.
64-144 J. Cdez.,
Bonnie I. Walton, City Clerk
Member and Secretary, Firemen's Pension Board
State of Washington Revenue Distribution Office of the State Treasurer
Date: 05/27/2008Treasury Management System
Time: 3:30 pm ,Fire Insurance Premiums ReportID:FireInsPrem
05/30/2008 Page 1 of 1
Ratio Value: 834.4604014599
Number of
Paid
City/District Firefighters Amount
0010 Aberdeen. 35 $ 29,206.11
0060 Anacortes CITY OF RENTON 23 19,192.59
0120 Bellevue 211 176,071.15
0130 •Bellingham MAY 3 0 2008 131 109,314.31
0190 Bothell ECEIVED 53 44,226.40
0200 Bremerton CITY CLERK'S OFFICE 54 45,060.86
0260 Camas 37 30,875.04
0320 Centralia 21 17,523.67
0330 Chehalis 13 10,847.99
0630 Edmonds 53 44,226.40
0660 Ellensburg 20 16,689.21
0730 Everett 179 149,368.41
0960 Hoquiam 23 19,192.59
1050 Kelso 12 10,013.52
1060 Kennewick 76 63,418.99
1070 Kent 158 131,844.74
1090 Kirkland 85 70,929.13
1230 Longview 43 35,881.80
1250 Lynnwood 53 44,226.40
1350 Mercer Island 29 24,199.35
1460 Moses Lake 26 21,695.97
1490 Mount Vernon 35 29,206.11
1660 Olympia 79 65,922.37
1730 Pasco 50 41,723.02
1770 Port Angeles 23 19,192.59
1830 Pullman 31 25,868.27
1840 Puyallup54 45,060.86
1870 Raymond 13 10,847.99
1890 Redmond 146 121,831.22
1900 Renton 103 85,949.42
1920 Richland 55 45,895.32 1
2030 Seattle 1,029 858,659.76
2070 • Shelton 9 7,510.14
2160 Spokane 277 231,145.53
2260 Sunnyside 14 11,682.45
2270 Tacoma 402 335,453.09
2330 Toppenish 5 4,172.30
2340 Tukwila 63 52,571.01
2400 Vancouver 181 151,037.33
2420 Walla Walla 48 40,054.10
2490 Wenatchee 34 28,371.65
2630 Yakima 84 70,094.67
i] 0179 King County Fire Dist#10 123 102,638.63
^. 0178
0327 King County Fire Dist#2 39 32,543.96
Spokane Fire Dist.#1 152 126,837.98
)' Totals 4,384 $ 3,658,274.40
045J 83095982
`gyp'—� h
MICHAEL J. MURPHY o $0 .429 cn
47-IF
Washington State Treasurer .t... F; '`;;, ‘;:)33 n,
ti1;r 05128/2008 s
.\ ;,�„ i. Post Office Box 40200 1
�� Olympia,WA 98504-0200 . . .; .: ���"'• mailed From98504 Y r
q�NING ..
8.
78
Ms. Bonnie Walton
City Clerk
City of Renton
1055 S. Grady Way
Renton,WA 98057
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's.`“ o ADMINISTRATIVE, JUDICIAL, AND
t3 LEGAL SERVICES DEPARTMENT
� ivTa� Office of the City Clerk
MEMORANDUM
DATE: June 12, 2008
TO: Members, Firemen's Pension Board
FROM: Bonnie Walton, City Clerk/Board Secretary& Member
SUBJECT: Cost of Living Increase Payable July 2008 - 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 3.9% annual increase in the CPI
percentage for All Urban Consumers in the Seattle area for 2007. A copy of the report is
attached.
I recommend that the Board adopt the 3.9% increase, effective July 1, 2008, and paid July 31,
2008.
cc: Linda Parks, Interim FIS Administrator
Bureau of Labor Statistics Data Page 1 of 1
U.S. Departent of ' • frit. . .,„,,,,i -.14-, .:1; 1 1 t 7,111::
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Data extractrAi s;: .=t<r:=. 11,F00 t<;:==9 1 AM)
Consumer Price Index - All Urban Consumers
3 12 Months Percent Change
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lArea: Seattle-Tacoma-Bremerton, WA
Item: All items
1Base Period: 1982-84=100
YearFeb° ..._. . Apr`,. .'. ...,,,,, _._...,Aug Sep Oct Nov Dec Annual lALN . N�1L i! ''
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1 1981 , I 12.7 2.9 12.9 '2.9
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2000= =3.2 =3.3 3.8 14.0 14.2 4.1 33.7 13.3 14.1
2001 '4.5 : 3.61 =4.0I 13,6 3.2 12.5 13.6 i4.0 3.2
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2002 2.0 =2.5 1.7 ' 11.9 j 1.6 1
2.1 11.9 12.1 11.8
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2006 11
" 3.0 '; 13.0 { 4.2 . ;4.9 _, 3.2 € i4.2 13.7 3.3 4.1
2007 4.0 I4.0 °° 13.5 13.0 . _....._.14.1 ._._._ _4.6 (3.9 3.9 13.8 j
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•
J
CITY OF RENTON - FIREMEN'S PENSION FUND
CASH & INVESTMENT ACTIVITY REPORT
AS OF MAY 31, 2008
Fireman's Pension Fund Comparison of Cash and Investment Activity
6
■2008 ❑2007
5
;! 1
3 —
2 -.
1
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
CURRENT 2008 2008 LAST YEAR 2007 2007
ACTIVITY: MONTH YTD BUDGET CURR MO ACTUAL ADJ BUDGET
BEGINNING CASH/INV BALANCE $4,514,867.86 $4,694,232.48 $4,203,347 $4,518,567.47 $4,672,241.19 $4,459,523
RECEIPTS:
Fire Insurance Premium Tax 85,949.42 85,949.42 75,000 85,061.56 85,061.56 73,000
Investment Interest 1,475.13 11,046.17 200,000 2,763.49 389,226.86 175,000
DISBURSEMENTS:
Fire Pension 41,489.16 220,997.10 477,400 34,532.96 427,011.96 463,500
Fire Pension Medical (2,899.29) 3,212.43 20,000 482.58 9,059.17 20,000
Office/Operating Supplies 0.00 0.00 459 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 4,145.00 9,948 686.00 8,226.00 8,226
ENDING CASH/INV BALANCE $4,562,873.54 $4,562,873.54 $3,970,540 $4,570,690.98 $4,694,232.48 $4,203,347
CURRENT PREVIOUS LAST YEAR LAST YEAR
ACTIVITY: MONTH MONTH CURR MO PREV MO
CASH $801,753.97 $753,748.29 $364,994.42 $312,855.20
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
TOTAL CASH AND INVESTMENTS $4,562,873.54 $4,514,867.86 $4,570,706.69 $4,518,567.47
The State Investment Pool interest 2.6998% 2.6998% 5.1936% 5.2260%
H:\FINANCE\FINPLAN\FIREPEN\1_Fire_Pension_2008.xls\May08 Page 1 6/13/2008
*ire
Nur FIREMEN'S PENSION BOARD
PENSION/MEDICAL PAYMENTS FOR JUNE, 2008
ANKENY, Charlie (Captain) $90.81 90.81
ASHURST, James (Assistant Chief) $4,569.00 720.29 5,289.29
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) $4,010.50 765.83 4,776.33
GOODWIN, Donald (Firefighter) $1,277.48 1,277.48
HAWORTH, Constance (Widow) $2,688.00 2,688.00
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
NEWTON, Roger(Firefighter) $231.19 231.19
NICHOLS, Gerald (Battalion Chief) $467.89 467.89
PARKS-ANDREASON, Arlene (Widow) $284.16 284.16
PARKS, John (Firefighter) $3,139.50 80.89 3,220.39
PHILLIPS, Bruce H. (Deputy Chief) $909.45 909.45
PRINGLE, Arthur(Captain) $421.16 421.16
PRINGLE, S. Joan (Widow) $2,309.31 2,309.31
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 - 3,025.00
TODD, Franklin (Firefighter) $420.32 420.32
TONDA, Lila Jean (Widow) $531.29 531.29
VACCA, Nick(Lieutenant) $265.10 265.10
WALLS, Kenneth (Firefighter D Step) $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) - -
WOOT,ENSp''`'�, Maril n E. Wido�QLw) q] a $200.10 200.10
Tri
'WM 135670t,
Prior Year Pension/Medical Payments:
Total Pension Payments for June, 2007 34,517.25
Total Medical Bills Reimbursed in June, 2007 49.81
Total Expenses: Medical/Pension 34,567.06
46/13/2008 2008.XLS 6/13/2008
Noe
FIREMEN'S PENSION BOARD
MEDICAL BILLS TO BE REIMBURSED IN JUNE, 2008 PAYMENT
2 James Ashurst Safeway 15.54
2 James Ashurst Safeway 76.56
2 James Ashurst Safeway 132.65
2 James Ashurst Safeway 11.99
2 James Ashurst Safeway 167.75
2 James Ashurst Safeway 11.99
3 James Ashurst Safeway 94.60
3 James Ashurst Safeway 132.65
3 James Ashurst Safeway 76.56
720.29
5 Charles Goodwin Bartell Drugs 72.51
5 Charles Goodwin Bartell Drugs 6.35
5 Charles Goodwin Bartell Drugs 6.88
5 Charles Goodwin Bartell Drugs 149.16
6 Charles Goodwin Bartell Drugs 149.16
6 Charles Goodwin Bartell Drugs 96.48
6 Charles Goodwin Bartell Drugs 6.88
6 Charles Goodwin Bartell Drugs 278.41
765.83
Jack Haworth 0.00
8 John Parks Olympic Drug 6.28
8 John Parks Olympic Drug 6.32
8 John Parks Olympic Drug 17.93
8 John Parks Olympic Drug 2.31
10 John Parks Olympic Drug 14.01
10 John Parks Olympic Drug 2.31
10 John Parks Olympic Drug 5.72
10 John Parks Olympic Drug 1.25
10 John Parks Olympic Drug 18.48
10 John Parks Olympic Drug 6.28
80.89
Karl Strom 0.00•
:'>/ /y G,"yqa / %� ;;1,0441.,,, � .yr t /1 �,/i5'"H 3 ,1CIP,f'tet^V;4 41;1!
3_2008 FP Medical.XLS Page 1 of 1 6/13/2008
's'' SENDCLAIMTO: `1 City of Renton
Finance Dept.-Fire Pension
1055 South Grady Way
Renton, WA 98057
O��Y 0�
+ iiiR +
"PN.NT..
CITY OF RENTON
FIREMEN'S PENSION BOARD
Pharmacy/Medical Claim Reimbursement Request
•
1)`b'ATE JUNE 6 2008
2) DISABILITY RETIREE'S NAME (print) JAMES F. ASHURST
3) ADDRESS 223 GARDEN AVE. N. #B
4) DISABILITY AT TIME OF RETIREMENT HYPERTENSION HBP
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.)
MEICATION FOR ABOVE PROBLEMS
6) TOTAL AMOUNT OF CLAIM: $ 740,. 29
Amount of total claim(above)that is related to the Retirement Disability: $ 5 51 . 63
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: _get/ .... 'd Ce.}(A.,„_,A5
Note: Supporting documentation must be attached.
•
hailer I
SAFEWA' ,flARMACY ' 9 WAY PHARMACY
(S) 200 SOUTH 3RDSTREET 200 SOUTH 3RD STREET
RENTON,WA 98055 ....V RENTON,WA 98055
#1563 (425)226-0325 1 #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 [NW]
17900 TALBOT RD S,STE 101 17900 TALBOT RD S, STE 101
RENTON,WA 98055 RENTON,WA 98055
Rx:6692842 Apr 08, 2008 Safety Cap: Yes Rx:6707635 Apr 28, 2008 Safety Cap: Yes
FUROSEMIDE 40MG TAB (SAND)Qty: 100 TAB FUROSEMIDE 40MG TAB (SAND)Qty: 100 TAB
Generic for:LASIX 40MG TAB A
Ref:A3084996940211 NDC:00781-1966-10 HSGIPSH NDC:00781-1966.10 HSGIRN
REGENCE BLUESHIELD WASHINGTN
Amount Due: $15.54 • Amount Due: $11.99
IVI II II
111111111111111
III II Rx 1 R
EFS FL I
TIONS fIIIIIIIIIIIIIIIII REFILL YOUR PRESCRIPTIONS
L�� SAfEWAY.COM
SAFEWAY PHARMACY / �DpV1ACY
(s) 200 SOUTH 3RD STREET
RENTON,WA 98055 RENTON,WA 98055
#1563 (425)226-0325 #($) (425)226-0325
Official Receipt- Please retain for tax or insurance Official Receipt- Please retain for tax or insurance
ASHURST,JAMES (425)255 6 154 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 [RS] DR. GRAVES,DANIEL [RF]
17900 TALBOT RD S, STE 101 17900 TALBOT RD S,STE 101
RENTON, WA 98055 RENTON,WA 98055
Rx:6706816 Apr 08, 2008 Safety Cap: Yes Rx:6699560 May 12, 2008 Safety Cap: Yes
HUMULIN N VIA (LILL) Qty: 20 ML PANTOPRAZOLE 40MG TAB (PRAS)Qty:50 TAB
Generic for:PROTONIX 40MG TAB
Ref:A2084994030911 NDC:00002.8315-01 HSGI Ref:A5085334077701 NBC:00008-0607-01 HSGIPSH
REGENCE BLUESHIELD WASHINGTN REGENCE BLUESHIELD WASHINGTN
Amount Due: $76.56 Amount Due: $167.75
1111 I 1 I I Ili 1I 1 1 1 ill1111
r.- \ f y,r', roe Hill
111111111
11
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@ SAFEWAI COM PRESCRIPTIONS
ti
SAFEWAY PHARMACY INYDPH VIACY
(S) 200 SOUTH 3RD STREET
RENTON,WA 98055 RENTON,WA 98055
#1563 (425)226-0325 # (425)226 0325
Official Receipt- Please retain for tax or insurance Dfticiat 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 DR. GRAVES,DANIEL [RF]
17900 TALBOT RD S, STE 101 [RF] 17900 TALBOT RD S,STE 101
RENTON,WA 98055 RENTON,WA 98055
Rx:6702058 Apr 24, 2008 Safety Cap: Yes Rx:6707635 May 16, 2008 Safety Cap: Yes
PLAVIX 75MG TAB (B-M ) Qty:30 TAB FUROSEMIDE 40MG TAB (WATS)Qty: 100 TAB
Generic for:FUROSEMIDE 40MG TAB
Ref:A1085158697621 NDC:63653.1171 O6 HAI Ref:A2085370516451 NBC:00591.0301.10 MTI
REGENCE BLUESHIELD WASHINGTN REGENCE BLUESHIELD WASHINGTN
Amount Due: $132.65 Amount Due: $11.99
OIIIIIIIIIIIIIIIIIIIIIIIIIIII =aRx=== @ SAFEWAY.COM REFILL YOUR PRESCRIPTIONS MIIIIIIIIIIIIIIIIIIIIIIIIIII !_ AS
""`1 R EFIL SAFEWAY.CUM ILL YOUR N0
(� t7
Plile/ Z
MORWAYDP ACY *of'
RENTON,WA 98055
#(.15$) (425)226-0325
Official Receipt- Please retain for tax or insurance
ASHURST,JAMES (425)255-6 154
223 B GARDEN AVE N. 12/17
RENTON,WA 98055
DR. GRAVES,DANIEL [RF]
17900 TALBOT RD S, STE 101
RENTON,WA 98055
Rx:6704477 May 20, 2008 Safety Cap: Yes
COZAAR 50MG TAB (MERC)Qty: 50 TAB
Ref:A7085417034271 N0C:00006-0952-31 BBA/SDP
REGENCE BLUESHIELD WASHINGTN
Amount Due: $94.60
1111 11111111 III! {1 II / Rx 1 REFILL
SAFEWAY.COM
MgYINDPIINWACY
RENTON,WA 98055
#1 (425)226-0325
Jtticial Keceipt - Please retain tor tax or insurance
ASHURST,JAMES (425)255-6154
223 B GARDEN AVE N. 12/17
RENTON, WA 98055
DR. GRAVES,DANIEL [RFi
17900 TALBOT RD S, STE 101
RENTON, WA 98055
Rx:6702058 May 20, 2008 Safety Cap: Yes
PLAVIX 75MG TAB (B-M ) Qty: 30 TAB
Ref:A2085415590491 NDC:63653-1171-06 BBA/SDP
REGENCE BLUESHIELD WASHINGTN
Amount Due: $132.65
I III �III�
11 11 1111/11i I )-1 )-j-,,REF safEvay. oM;
A, IIACY
RENTON,WA 98055
Il #1 (425)226-0325
Utt�cial
lieceipt - Please retain for tax or insurance
ASHURST,JAMES (425)255-6154
223 B GARDEN AVE N. 12/17
RENTON,WA 98055
DR. GRAVES,DANIEL [RFS
17900 TALBOT RD S, STE 101
RENTON,WA 98055
Rx:6706816 May 20, 2008 Safety Cap: Yes
HUMULIN N VIA (LILL) Qty: 20 ML
Ref:A4085415589101 NDC:00002.8315.01 BRA/SDP
REGENCE BLUESHIELD WASHINGTN
Amount Due: ''$76.56
III II I11I III
Rx_1� ° REFILL
YOUR PRESCRIPTION,'
Tale, 3
Nor SEND CLAIM TO: "" City of Renton
Finance Dept.-Fire Pension
1055 South Grady Way
Renton, WA 98057
Yee
CITY OF RENTON
FIREMEN'S PENSION BOARD
Pharmacy/Medical Claim Reimbursement Request
1) DATE �/7 Q(f
2) DISABILITY RETIREE'S NAME (print) /Mit WE 24, G6op I /V
3) ADDRESS /qiq Md/Mae A-(16 Ale– — E� � (1.4 rs2,0E--6
_ •
4) DISABILITY AT TIME OF RETIREMENT /61it.t e,4�'�;G&X; �'l l / f
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,so ce or insurance coverage Supporting documentation for all must be attached.)
6) TOTAL AMOUNT OF CLAIM: $ f3 �-
Amount of total claim (above) that is related to the Retirement Disability: $ 7�J a2-3
7) I certify that I have not been and will not be compensated by any other organization,
insurance carrier or Medicare for the above-mentioned claim for reimbursement 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:ZJ'C -, ,
Note: Supporting documentation must be attached.
1'a *
. -57/7/ I
'7 4 : 144A-4-661
16x,611‘ jili 401141
. /2"e,rm...„,pf,
PR-din: C..i 61-4-4 ( ._ e-- A. -,--0 6 D cc) ( ilk—
BARTELL DRUGS
( BARTELL DRUGS
®w..n�r,«,,a.a n,w,rra,..�
—W.. iag.i,Oi.n.,,,bne.�.� Rx# 45-406674 E DR. FLO, GAYLE
R" 45-406676 E DR- FLO, GAYLE DATE: 03/27/08 R (425)251-5110
DATE: 03/27/08 R (425)251-5110 NAME: CHARLES GOODWIN
NAME: CHARLES GOODWIN 1414 MONROE AVE NE#306
1414 MONROE AVE NE#306 ATENOLOL 50MG TABLET(*TEVA)
GEMFIBROZIL 600MG TABLET(*AP 00093-0752-10 81932011
60505-0034-08 81393011
REFILL 2 QUANTITY 30.00
REFILL 1 QUANTITY 180.00 BARTELL DRUGS PRICE= $13.49 r
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BARTELL DRUGS PRICE= $91.78 70 C/ WITH XPS THE AMOUNT DUE 46.88 /d
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WITH XPS THE AMOUNT DUE 472.51 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
WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR
WE TRULY APPRECIATE YOUR BUSINESS.TO PROVIDE YOU REFILLS 24-48 HOURS IN ADVANCE
WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR L I
REFILLS 24-48 HOURS IN ADVANCEL. I
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I BARTELL DRUGS BARTELL DRUGS
Rx# 4381218 E DR. OL's Owes R RALD Rx# -"'457/6grr o IFF ALIDA
DATE: 03/27/08 R (425)251-5110 DATE: 03/25/08 R (425)899-3123
NAME: CHARLES GOODWIN NAME: CHARLES GOODWIN
1414 MONROE AVE NE#306 1414 MONROE AVE NE#306
ALLOPURINOL 100MG TABLET(*PA AGGRENOX CAP 200/2580125918 /` q
49884-0602-10 81935011 00597-0001-60 / `rk
REFILL 3 QUANTITY 30.00 l/� 3(' REFILL 1 QUANTITY 60.00 /��
BARTELL DRUGS PRICE= $10.99 `/ BARTELL DRUGS PRICE= $195.99
WITH XPS THE AMOUNT DUE$6.35 WITH XPS THE AMOUNT DUE1J 49.16
BARTELL DRUGS#45 BARTELL DRUGS#45
(425)793-1015 (425)793-1015
4700 NE 4TH STREET 4700 NE 4TH STREET
RENTON,WA 98059 RENTON,WA 98059
THANK YOU THANK YOU
WE TRULY APPRECIATE YOUR BUSINESS.TO PROVIDE YOU WE TRULY APPRECIATE YOUR BUSINESS. TO PROVIDE YOU
WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR
L REFILLS 24-48 HOURS IN ADVANCEI REFILLS 24-48 HOURS IN ADVANCE I
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BARTELL DRUGS 1 BARTELL DRUGS
Washington's Own Drugstores R" 45-406 'E DR. FLO, GAYLE
Rx# 45-406699 E DR. GRIFFITH,ALIDA
DATE: 05/09/08 R (425)251-5110
DATE: 04/27/08 R (425)899-3123
NAME: CHARLES GOODWIN
NAME: CHARLES GOODWIN 1414 MONROE AVE NE#306
1414 MONROE AVE NE#306
ATENOLOL 50MG TABLET(*TEVA)
AGGRENOX CAP 200/25 00093-0752-10 83266058
00597-0001-60 82254984
REFILLREFILL 1 QUANTITY 30.00
NO QUANTITY 60.00
BARTELL DRUGS PRICE= $13.49
BARTELL DRUGS PRICE= $195.99 (,, �/
WITH XPS THE AMOUNT DUE 4149.16
f(-(61` ( `V WITH XPS THE AMOUNT DUE 46.88 �D O
BARTELL BARTELL DRUGS#45
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 I L I
I BARTELL DRUGS
R" -- iashington's Own Dragstores' ...... .w..' I BARTELL DRUGS
45-406673 E DR. FLO, GAYLEMistimes
DATE: 05/02/08 R (425)251-5110 ator
Rxs 45-431 E DR• GRIFFITH,ALIDA
NAME: CHARLES GOODWIN DATE: 05/12/08 N (425)899-3123
1414 MONROE AVE NE#3061414: CHARLES GOODWIN
AMLODIPINE 10MG TABLET(*LUP)- 1414 MONROE AVE NE#306
68180-0752-03 83741372 CARE •PA/LEVODOPA 001
00093-1 11 83108593108593
REFILL 1 QUANTITY 100.00 w
BARTELL DRUGS PRICE= $249.29 REFILL 4 QUANTITY 540.00
BARTELL DRUGS PRICE= $388.99 p I
WITH XPS THE AMOUNT DUE 496.48 ale' (11
BARTELL DRUGS#45 WITH XPS THE AMOUNT DUE 4278.41
(425)793-1015 BARTELL DRUGS#45 /p N
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 BEST SERVICE POSSIBLE PLEASE ORDER YOUR WE TRULY APPRECIATE YOUR BUSINESS.TO PROVIDE YOU
L REFILLS 24-48 HOURS IN ADVANCE WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR
L REFILLS 24-48 HOURS IN ADVANCE
044 Pl-Gil5' D ' Vd-kit(0 111.1144
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SEND CLAIM TO: City of Renton
Neer
'teeFinance Dept.-Fire Pension
1055 South Grady Way
Renton, WA 98057
Gti(cY 0th
CITY OF RENTON
FIREMEN'S PENSION BOARD
Pharmacy/Medical Claim Reimbursement Request
1) DATE M4}(3
y (print) \Io �2 �. , �c�y`/L5
2) DISABILITY RETIREE'S NAME rint . !,� c �y
3) ADDRESS h3 � p�Y�' /0Jq► 1- '` vi YID' �� / 06t ja,
4) DISABILITY AT,TIME O RETIREMENT b �,-` - ►S „ j S �a'S�-
/Q. t°- r`�l f i frk-ti 1 & a-of c A yt x 1 --7-Y 4°1-ate J a'nf
5) DESCRIPTION OF CLAIM: (Supporting documentation must be attached.)
(Note: Medical coverage is limited to current treatment of the retiree's disability as
determined at the time of retirement. (RCW 41.18) Submit only claims that relate to
item#4.)
6�I e4 tsei n€ A ,- 6-1-6 -r & ,4 la / -Kir;e l
y
Pi-04) 117 s
6) TOTAL AMOUNT OF CL�?.I1C�1 e c
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.
Si ature. ,*1(
1.� -
Note: Supporting documentation must be attached.
Pale' 1
Value at the smiling'0'
YMPIC DRUG RECEIPT
124415th Ave.,Longview,WA 98632 Ph.(360)423-3360 SAVE FOR INSURANCE
OR TAX RECORDS
Rx# C768297 For JOHN PARKS
4-02-08 CRN:A0084931595811 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
NI 1111111111111111111111111 liii II II 11 I II I II Price
Value at the smiling'0'
YMPIC DRUG RECEIPT
1244 15th Ave.,Longview,WA 98632 Ph.(360)423-3360 SAVE FOR INSURANCE
OR TAX RECORDS
Rx# 711222 For JOHN PARKS
4.02.08 CRN:88084933229701 1335 3RD AVE#109
LONGVIEW,WA 98632 (360) 577.6684
LACTULOSE SOL 10GI15ML
#1400 NC: 60432-0037-32
DR. RICHARDS,JOHN E ZHA COPAY: $6.32
111111 II III II 11 11 11 111 II 11 11 11 11 11 111111 IIIIrce
YVMPIC ODRUG RECEIPT
124415th Ave.,Longview,WA 98632 Ph.(360)423-3360 SAVE FOR INSURANCE
OR TAX RECORDS
Ret 768295 ForJOHN PARKS
4-02-08 CRN:08084831593811 1335 3RD AVE#109
LONGVIEW,WA 98632 (3601 577.6684
MIRTAZAPINE SOLTAB 45MG
#30 NC: 65862-0023-06
DR. RICHARDS,JOHN E ZHA COPAY: $17.93
II MI lII II I I I II 1 1 1 1 1 1 II III 1011 II II II I I 1111111 II Price
dew' D
Value atMeamilinp'O' RUG
RECEIPT
YMPIC
124415th Ave.,Longview,WA 98632 Ph.(360)423-3360 SAVE FOR INSURANCE
OR TAX RECORDS
Rad C182299 For JOHN PARKS
4-11-08 CRN:A1085021160191 1335 3R0 AVE#109
LONGVIEW,WA 98632 (3601 577.6684
ZOLPIDEM TAB 10MG
35 2605.08
RICHARDS,JOHN
ER. ZHA COPAY: $2.31
UIO IU IIIII IIII IU11111111 11 11 III 11001111 I1I IIII IIII 101 III Prlce •
ThjevB
No'w' SEND CLAIM TO: City of Renton
Finance Dept.-Fire Pension
1055 South Grady Way
Renton, WA 98057
wArro
CITY OF RENTON
FIREMEN'S PENSION BOARD
Pharmacy/Medical Claim Reimbursement Request
1) DATE LJ g 003
,
2) DISABILITY RETIREE'S NAME (print) � d � �„ , fEiçJ2S
3) ADDRESS t 3r5 — '. f] e J 072 / W4, cisg 3
4) DISABILITY AT TIME OF RETIREMENT j d yy e k k2°14x or rte$6".-17
��rer"s ) 1�I°are? L e-rt22>1 a 7,d x f e. "y Pry t e-rn
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.)
t4/1 [ili o ]'` J!' !✓� d�,1 �Y1 ci A Je+ �
pc-rokf e ern,s
O11 t' 1— i c -te --0'
07- ( 61 d 4 B-rae-h.r1 r'S
6) TOTAL AMOUNT OF CLAIM: $
Amount of total claim (above) that is related to the Retirement Disability: $ 1/1, 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.
r �
Signature:` •
Note: Sup.'. ting documentation must be attached.
Ride/.1
Value at the.- "'3-'p'
lat0' DRUG RECEIPT"e
124415th Ave.,Longview,WA 98632 Ph.(360)423-3380 SAVE FOR INSURANCE
Ax# 768295 OR TAX RECORDS
5-01-081 1335 3RD PARKS OR
CRN:A9085227883751
LONGVIEW,WA 98632 (3601 577-6684
MIRTAZAPINE SOLTAB 45MG
#30 NDC: 65862-0023-06
DR. RICHARDS,JOHN E ZHA COPAY: $14.01
11111111 I VIII IIIIIIIIIIIII IIIIIIIIIIIIIII VIII VIII III�I VIII VIII VIII 1111111111 VIII VIII VIII VIII III IIII Pnce
Value et the emiling'0'
YMPKDRVG RECEIPT
124415th Ave.,Longview,WA 98632 Ph.(360)423-3360 SAVE FOR INSURANCE
OR TAX RECORDS
Rx# C782299 For. JOHN PARKS
5-12-08 CRN:A0085333135681 1335 3RD AVE#109
' LONGVIEW,WA 98632 (360) 577-6684
ZOLPIDEM TAB 10MG
3DJOHN
60505-2605-08
DR. RICHARDSZHA COPAY: $2.31
III 11 I Oil IIII I II IIII II 110011 II 1111 Il J Price
Value at the.smiling'0'
► I DRUG RECEIPT
FOR
124415th Ave.,Longview,WA98632 Ph.(360)423-3360 SAVE OR TAX RECORDS INSURANCE
Rx# 793387 For. JOHN PARKS
5-19.08 CRN:07085409444101 1335 3RD AVE#109
LONGVIEW,WA 98632 (360) 577-6684
AZITHROMYCIN 500M PAK
DR. RICHARDS,JOHN1E1-0788-67 ZHA COPAY: $5.72
I 111111111 II I I II II 111111 II II II II I I II I III Pri
ce
Value at thosmiling'� RECEIPT
FOR
124415th Ave.,Longview,WA 98632 Ph.(360)423-3360 SAVE OR TAX RECORDS INSURANCE
Rx# 793389 For: JOHN PARKS
5.19.08 CAN:06085401612371 1335 3RD AVE#109
LONGVIEW,WA 98632 (360) 577-6684
PREDNISONE 20MG
I0 NDC: 00143-1477-05
RICHARDS,JOHN
DR. ZHA COPAY: $1.25
11011 IIIIII 11 III I0II0 II II 11 II II 11111 II II I II Price
Value et theemlinl'0'
PR!DRUG RECEIPT
124415th Ave.,Longview,WA 98632 Ph.(360)4233380 SAVE FOR INSURANCE
OR TAX RECORDS
Rx# 768298 For JOHN PARKS
5.19.08 CRN:A7085407858721 1335 3RD AVE#109
LONGVIEW,WA 98632 (360) 577-6684
OMEPRAZOLE CAP 20MG ***
90 NDC: 5-0118 RICHARDS,JOHNI43
E
DR. ZHA COPAY: $18.48
11111111 OIIII I II I II I I li1101111111111 III II I III I III Price
Vale.at theemeng'0'
�'► - DRUG RECEIPT
1244 15th Ave.,Longview,WA 98632 Ph.(360)4233360 SAVE FOR INSURANCE
OR TAX RECORDS
Rx# C793384 For: JOHN PARKS
5.19.08 CAN:84085401805591 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
��� liii 0111111 lI 111101111110111110 II II 11 1111111111 II II II Pri
ce