Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-casd-3_06-cv-00791/USCOURTS-casd-3_06-cv-00791-0/pdf.json

Nature of Suit Code: 863
Nature of Suit: Social Security - DIWC/DIWW (405(g))
Cause of Action: 42:405 Review of HHS Decision (DIWC)

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UNITED STATES DISTRICT COURT

SOUTHERN DISTRICT OF CALIFORNIA

KIM-FUN W. WU,

Plaintiff,

CASE NO. 06cv0791 BTM (JMA)

ORDER GRANTING PLAINTIFF’S

MOTION FOR SUMMARY

JUDGMENT AND DENYING

DEFENDANT’S CROSS-MOTION

FOR SUMMARY JUDGMENT

vs.

JO ANNE B. BARNHART,

COMMISSIONER, SOCIAL SECURITY

ADMINISTRATION,

Defendant.

I. INTRODUCTION

Plaintiff Kim-Fun W. Wu claims she became disabled on January 31, 1994 due to

depression, a somatization disorder, and a personality disorder. On November 18, 2002

Plaintiff filed an application for Disability Insurance Benefits and her application was

denied both initially and on reconsideration. (Tr. 17, 26-29, 31-34.) Administrative Law

Judge Peter J. Valentino (“ALJ”) held a hearing on November 5, 2004 and, in a decision

filed on January 19, 2005, found Plaintiff not disabled and therefore ineligible for Disability

Insurance Benefits. (Tr. 17-23.) The ALJ’s decision, on behalf of the Social Security

Commissioner, became final when the Appeals Council declined to review his findings. 

(Tr. 4-6.) 

Plaintiff presently seeks judicial review of the ALJ’s decision under 42 U.S.C. §

405(g). For the reasons discussed below, the Court GRANTS Plaintiff’s motion for

summary judgment, DENIES Defendant’s cross-motion for summary judgment, and

reverses and remands the decision of the ALJ.

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1 Principally used “[t]o treat symptoms of major depression, obsessive-compulsive

disorder, and social anxiety disorder.” Simeon Margolis, The Johns Hopkins Consumer

Guide to Drugs 579 (2002).

2

 Principally used for insomnia. See id. at 713.

3 Prescribed for anxiety and insomnia. See id. at 455.

4

 Prescribed to treat “psychotic conditions (severe mental disorders characterized by

distorted thoughts, perceptions, and emotions), such as schizophrenia.” See id. at 594.

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II. FACTUAL BACKGROUND

Plaintiff is a woman of 66 years with a college degree and post-graduate

education. (Tr. 51, 76, 119.) She worked as a computer programmer prior to onset of the

alleged disability on January 31, 1994 due to depression, a somatization disorder, and a

personality disorder. (Tr. 482.) Plaintiff met the disability insured status requirements of

Title II of the Social Security Act between January 31, 1994 and June 30, 1999, the

disability period presently under review. 42 U.S.C. §§ 401-33. (Tr. 26.) 

Plaintiff has a family history of suicide and suicide attempts, including her father,

brother, and grandmother, as well as a personal history of recurrent depressive issues

dating back to 1968. (Tr. 122, 160-61, 170, 172, 325.) Prior to onset of the alleged

disability, Plaintiff went on short-term disability leave at least twice as a result of

depression. (Tr. 79, 183.) 

Between July 1988 and June 22, 1995, Dr. Richard Kerley regularly treated

Plaintiff in Kaiser Permanente’s Department of Psychiatry. (Tr. 217-18, 142, 140-218.) 

During those seven years, Dr. Kerley treated Plaintiff on numerous occasions, including

at least 11 times between onset of the alleged disability and their last consultation on

June 22, 1995. (Tr. 176-217.) Dr. Kerley prescribed Plaintiff a number of antidepressants during the alleged disability period, predominately Paxil,1

 Restoril,2 Ativan,3

and Trilafon.4 (Tr. 178.) 

On February 2, 1995, Dr. Kerley diagnosed Plaintiff with “recurrent major

depression which has been only partially responsive to various anti-depressants.” (Tr.

183.) Dr. Kerley stated that although Plaintiff had received non-psychiatric treatment and

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5 See Margolis, supra, at 534.

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various diagnoses from a number of doctors, he believed her “psychiatric problems are

primary and are related to a mixture of personality problems, depression, and

somatization/conversion.” (Id.) In closing, Dr. Kerley opined that Plaintiff “is indeed

highly symptomatic and very distressed. I doubt she could hold any job and avoid getting

into severe difficulty because of her limitations in inter-personal relations.” (Id.)

In the summer of 1995, Plaintiff moved to Hong Kong and remained there until

sometime in 1997. (Tr. 176, 486-87, 492.) Although complaining of depression while

abroad, Plaintiff medicated herself and did not seek professional treatment. (Tr. 487.) In

May 1999, after returning to the United States, Plaintiff joined a depression study through

which she was prescribed Serzone, a drug used to treat major depression.5 (Tr. 147,

160, 488-89.) Plaintiff participated until October 1999 when, at the behest of the study’s

attending physician, she returned to regular psychiatric treatment. (Tr. 19, 490.) 

In May 2000, psychologist Alex B. Caldwell, Ph.D., conducted the Minnesota

Multiphasic Personality Inventory-2 Test (“MMPI-2") on Plaintiff. (Tr. 220-230.) In his

final report, Dr. Caldwell diagnosed Plaintiff with borderline states, transient

decompensations, mixed personality disorders, depression, and paranoid personality

disorders. (Tr. 222-23.) He stated Plaintiff’s behavior under stress “is likely to become

seriously inappropriate if not borderline psychotic” and “others are apt to see her as

unpredictable, difficult, and hard to understand” despite her attempts to cover her hostility,

resentment, and irritability. (Tr. 221.) Dr. Caldwell also noted Plaintiff’s profile “suggests

a severe suicide risk.” (Tr. 223.)

Plaintiff’s various treating psychiatrists between 2002-2004, including physicians

from Scripps Clinic and UCSD Outpatient Psychiatric Services, all concluded Plaintiff’s

severe major depressive disorder, somatization disorder, and personality disorder

precluded her from working. (Tr. 260, 362, 365, 410.)

In 2003, state physicians reviewed Plaintiff’s file. (Tr. 329-344.) Dr. Ed O’Malley

concluded on the Psychiatric Review Technique Form (“PRTF”), without comment, that

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there was insufficient evidence to diagnose Plaintiff with a medically determinable

impairment, and his decision was affirmed by another state physician. (Tr. 329-342.) 

Upon a third review, state physician Stuart Brodsky, D.O., agreed with the decision and,

again without additional notation, concluded “there [was] insufficient evidence during that

period in which to adjudicate from a physical standpoint.” (Tr. 344.) 

III. THE ALJ’S DECISION

The Social Security Regulations mandate a five-step sequential evaluation to

determine whether a claimant is disabled within the meaning of the Social Security Act

(“Act”). The five steps are as follows: (1) Whether the claimant is presently working in

any substantial gainful activity. If so, claimant is not disabled. If not, the evaluation

proceeds to step two. (2) Whether claimant’s impairment is severe. If not, claimant is not

disabled. If so, the evaluation proceeds to step three. (3) Whether the impairment meets

or equals a specific impairment listed in Appendix 1 to Subpart P of Part 404. If so,

claimant is disabled. If not, the evaluation proceeds to step four. (4) Whether claimant is

able to do any work she has done in the past. If so, claimant is not disabled. If not, the

evaluation continues to step five. (5) Whether claimant is able to do any other work. If

not, claimant is disabled. Conversely, if the Commissioner can establish there are a

significant number of jobs in the national economy available to one of claimant’s abilities,

the claimant is not disabled. 20 C.F.R. § 404.1520. See also Tackett v. Apfel, 180 F.3d

1094, 1098-99 (9th Cir. 1999).

The ALJ determined that (1) Plaintiff had not engaged in substantial gainful activity

since the onset of her alleged disability, but (2) she nonetheless lacked a “severe”

impairment lasting, or expected to last, at least 12 continuous months. (Tr. 18-19.) 

Specifically, the ALJ concluded Plaintiff’s impairments were non-severe and did not

significantly limit her physical or mental ability to conduct basic work activities such as

“understanding, carrying out and remembering simple instructions; use of judgment;

responding appropriately to supervision, co-workers and usual work situations; and

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dealing with changes in a routine work setting.” (Tr. 18.); See 20 C.F.R. § 404.1521(b). 

The ALJ found that Plaintiff’s impairment was not “severe” at step two because: Dr.

Kerley’s disability opinion was entitled to little weight; Plaintiff traveled “frequently” prior to

1999; she got better after moving to Hong Kong and did not seek psychiatric treatment

again until 1999; during this time period, she engaged in daily activities like dancing,

gardening, cooking, computer work, volunteer work, and involvement with her home

owners association; and the medical records show that she suffered only from episodic

bouts of depression that improved within a short time of treatment. (Tr. 19, 21-2.) 

In finding Plaintiff’s impairments were “non-severe,” the ALJ accorded “little weight”

to Dr. Kerley’s opinion that Plaintiff’s impairments rendered her disabled for the following

reasons: Plaintiff saw Dr. Kerley only eleven times between January 1, 1994 and June

22, 1995; clinical observations showed Plaintiff lacked suicidal or homicidal ideations; she

had no decrease in logical thinking despite forgetfulness; the opinion conflicted with the

weight of the medical evidence and was unsupported by acceptable clinical and

laboratory findings. (Tr. 20.); See 20 C.F.R. § 404.1527(d)(2); Social Security Regulation

(“SSR”) 96-2p. 

IV. DISCUSSION

Plaintiff contends that (1) the ALJ improperly rejected the opinion of Plaintiff’s

treating physician Doctor Kerley; and (2) the ALJ’s decision was not supported by

substantial evidence in the record. The Court finds the ALJ’s rejection of Doctor Kerley’s

opinion was improper because it was not based on specific and legitimate reasons

supported by substantial evidence in the record. Therefore, crediting Dr. Kerley’s opinion

as a matter of law, the ALJ’s finding that Plaintiff’s impairment was not “severe” is not

supported by substantial evidence. 

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A. Standard of Review

The Commissioner’s denial of disability benefits will be disturbed on appeal only

where the ALJ’s findings are based on legal error or are unsupported by substantial

evidence. Penny v. Sullivan, 2 F.3d 953, 956 (9th Cir. 1993). Substantial evidence

means more than a scintilla, but less than a preponderance of relevant evidence, and is

evidence such that reasonable minds, considering the entirety of the record, might accept

as support for the conclusion. Baxter v. Sullivan, 923 F.2d 1391, 1394 (9th Cir. 1991). 

The court must weigh the evidence that supports and detracts from the ALJ’s conclusion

and, where the evidence tends to support either outcome, the Court cannot substitute its

own opinion for that of the ALJ. Martin v. Heckler, 807 F.2d 771, 772 (9th Cir. 1986);

Matney v. Sullivan, 981 F.2d 1016, 1018 (9th Cir. 1992). 

B. Rejection of Treating Physician’s Opinion

As a general matter, opinions of treating physicians are given controlling weight

when supported by medically acceptable diagnostic techniques and when not inconsistent

with other substantial evidence in the record. See 20 C.F.R. § 404.1527(d)(2); SSR 96-

2p. Where a treating doctor’s opinion is contradicted by another doctor, the ALJ may not

reject the treating physician’s opinion without providing “specific and legitimate reasons”

supported by substantial evidence in the record. Reddick v. Chater, 157 F.3d 715, 725

(9th Cir. 1998). In doing so, the ALJ must do more than proffer his own conclusions – he

must set forth his own interpretations and why they are superior to that of the treating

physician’s. Embrey v. Bowen, 849 F.2d 418, 421-22 (9th Cir. 1988). The ALJ may meet

this burden by conducting a detailed and thorough discussion of the facts and conflicting

evidence, and by explaining his interpretations and findings. Magallanes v. Bowen, 881

F.2d 747, 751 (9th Cir. 1989). 

In the present instance, Dr. Kerley’s psychiatric opinion was contradicted by the

State’s reviewing physicians and, therefore, the ALJ must proffer “specific and legitimate

reasons” to properly reject his opinion. Reddick, 157 F.3d at 725; (Tr. 344.) Upon review

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of the record, the Court finds that the ALJ’s proffered reasons for rejecting Dr. Kerley’s

opinion were not legitimate and were not supported by substantial evidence.

First, although the ALJ stated “Dr. Kerley’s mental status exams showed no

evidence of suicidal or homicidal ideations or hallucinations,” Plaintiff’s clinical records

reflect otherwise. (Tr. 20.) Dr. Kerley’s clinical observations indicate that Plaintiff had

recurrent suicidal ideations, noting she “longs for death,” “cannot stand it any more,” had

“no desire to live,” “wants to die,” “thinks she’ll die soon,” has “suicidal thoughts without

plan or intent,” “felt suicidal,” and had plans to cut her wrists and “jump” but did not

attempt suicide. (Tr. 182, 162, 176, 184, 173, 164, 167.) While the record indicates

Plaintiff was occasionally free of suicidal machinations, an ALJ may not selectively focus

on aspects of clinical observations tending to suggest non-disability while ignoring regular

signs indicating the contrary. Edlund v. Massanari, 253 F.3d 1152, 1159 (9th Cir. 2001).

Second, the ALJ noted Plaintiff lacked a “decrease in ability to think logically

despite complaints of forgetfulness.” (Tr. 20.) Although Dr. Kerley’s notes of April 19,

1995 indicate that Plaintiff had “complaints of forgetfulness, but no decrease in ability to

think logically,” other medical records reflect that Plaintiff’s forgetfulness and lack of

concentration were significant enough to interfere with her ability to function. According

to other notes of Dr. Kerley, Plaintiff’s concentration was “always bad” and she had

trouble remembering tasks “from one minute to the next,” had difficulty making simple

decisions, was very disorganized, was having trouble with household chores, and “[g]ets

disoriented because she has trouble maintaining her attention.” (Tr. 180, 182.) 

Additionally, later medical records noted that Plaintiff had trouble remembering when

depressed and was “absent-minded.” (Tr. 120, 161.) 

Third, the ALJ accorded Dr. Kerley’s opinion little weight because Plaintiff saw him

“only eleven times between January 1, 1994 and June 22, 1995.” (Tr. 20.) 

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However, it appears that the ALJ did not fully consider Plaintiff and Dr. Kerley’s longstanding treatment relationship – a relationship spanning seven years with numerous

visits. (Tr. 176-217.) The opinions of treating sources are preferred over all others in part

because these medical sources are best able to provide a “detailed, longitudinal picture”

of the claimant’s impairment and, only where it is shown the physician did not treat the

patient long enough to obtain the requisite perspective, is the opinion entitled to little

weight. Holohan v. Massanari, 246 F.3d 1195, 1202 n.2 (9th Cir. 2001); See 20 C.F.R.

§§ 404.1527(d)(2), (d)(2)(i). Here, there is no reason to conclude that seven years of

treatment and 11 visits in 18 months is a frequency inconsistent “with accepted medical

practice” such that Dr. Kerley was unable to obtain a longitudinal picture of Plaintiff’s

impairment. See 20 C.F.R. § 404.1502.

Fourth, despite the ALJ’s contention Dr. Kerley’s findings are unsupported by

acceptable clinical findings, Dr. Kerley’s records contain ample clinical observations

corroborating his opinion. (Tr. 20.) Among other things, Dr. Kerley observed that

Plaintiff was “frequently tearful,” “depressed,”and “sad.” (Tr. 176, 177, 180.) Dr. Kerley

also observed that Plaintiff was “anxious, angry, argumentative, [and] depressed,” and

was “hyper-emotional - alternatively crying, laughing, or angry.” (Tr. 180, 184, 185.) 

Dr. Kerley’s clinical psychiatric notations are sufficient support for Dr. Kerley’s

opinion because objective laboratory results are not the exclusive means for supporting a

conclusion of disability; a finding of disability may also be predicated on medicallyacceptable clinical diagnoses. Bilby v. Schweiker, 762 F.2d 716, 719 (9th Cir. 1985). 

Clinical observations and diagnoses of treating psychiatrists and psychologists are

essential to a mental disability inquiry because psychiatric impairment is “not as readily

amenable to substantiation by objective laboratory testing.” Christensen v. Bowen, 633

F.Supp. 1214, 1220-21 (N.D. Cal. 1986) (quoting Lebus v. Harris, 526 F.Supp. 56, 60

(N.D. Cal. 1981)); See also SSR 85-16. Although a medically determinable mental

impairment cannot be established by symptoms alone, an anatomical, physiological, or

psychological abnormality that can be shown by medically acceptable clinic diagnostic

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techniques – including assessment by psychiatrists or psychologists – represents a

medical “sign” rather than “symptom.” SSR 96-4p n.2; 20 C.F.R. app. 1, subpt. P,

12.00(B) § 404. Accordingly, it is improper to require that mental disabilities be

established by precise scientific methods or laboratory results. Christensen, 633 F. Supp

at 1220-21; 42 U.S.C. § 423(d)(3). 

Moreover, in May 2000, Dr. Caldwell conducted the MMPI-2 Test on Plaintiff and

found her behavior under stress “is likely to become seriously inappropriate if not

borderline psychotic,” that “others are apt to see her as unpredictable, difficult, and hard

to understand,” her “[p]attern suggests a severely depressed emotional tone,” and her

“profile suggests a severe suicide risk.” (Tr. 221-223.) The report concluded Plaintiff

suffered from depression, borderline states, transient decompensations, and mixed and

paranoid personality disorders. (Tr. 222.) Although the report post-dates the disability

period under adjudication, it is nonetheless germane because most medical reports “are

inevitably rendered retrospectively and should not be disregarded solely on that basis.” 

Smith v. Bowen, 849 F.2d 1222, 1225-26 (9th Cir. 1988). The SSA specifically endorses

the MMPI-2 Test as a “well-standardized psychological test” that is useful in establishing

the existence of a mental impariment. 20 C.F.R. app. 1, subpt. P, 12.00(D) § 404.

None of the ALJ’s proffered reasons for rejecting Dr. Kerley’s opinion provide a

specific and legitimate basis supported by substantial evidence in the record. In reaching

this conclusion, the Court notes that major depressive disorder is, by its very nature,

episodic. It involves periodic waxing and waning of symptoms, including complete

symptomatic resolution before onset of other distinct depressive episodes. American

Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders 369 (Text

Revision 4th ed. 2000). “That a person who suffers from . . . anxiety, and depression

makes some improvement does not mean that the person’s impairments no longer

seriously affect her ability to function in a workplace.” Holohan, 246 F.3d at 1205; See

also Lester v. Chater, 81 F.3d 821, 833 (9th Cir. 1996). Here, Plaintiff’s episodic

depression, interspersed with occasional symptom-free periods, is not inconsistent with

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6

 The five-point scale involves ratings of “none, mild, moderate, marked, and extreme.”

Episodes of decompensation are rated on a four-point scale. 20 C.F.R. § 404.1520a(c)(4).

7 The Court notes that the ALJ failed to make specific findings as to the degree of

limitation in the four functional areas as required by SSA regulations. 20 C.F.R. §

404.1520a(e)(2) (“The [ALJ’s] decision must include a specific finding” on the four functional

limitations) (emphasis added). Further, the PRTF failed to rate Plaintiff’s degree of functional

limitation at the initial administrative review level or upon review by the ALJ as required by

20 C.F.R. § 404.1520a(d)(2). (Tr. 339.) However, the Court does not find it necessary to

remand to the ALJ to make these findings because the evidence clearly indicates Plaintiff’s

impairment is “severe.” Cf. Gardner v. Smith, 368 F.2d 77, 86 (9th Cir. 1966) (explaining that

where the record is fully developed, the Court can make a final determination and evaluate

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major recurrent depression. 

When the ALJ incorrectly rejects a treating physician’s opinion, the court credits

that opinion as a matter of law. Lester, 81 F.3d at 834. When according Dr. Kerley’s

opinion proper weight, it is readily apparent Plaintiff’s impairment was “severe” within the

meaning of the Act. In evaluating mental impairments at step two, the ALJ must rate a

claimant’s functional limitations on a five-point scale in four broad areas: activities of daily

living; social functioning; concentration, persistence, or pace; and episodes of

decompensation.6

 20 C.F.R. §§ 404.1520a(c)(3)-(4). The inquiry is merely a “de minimis

screening device to dispose of groundless claims,” and unless a finding of non-severity is

clearly established by the evidence, the sequential evaluation must proceed to step three. 

Smolen v. Chater, 80 F.3d 1273, 1292 (9th Cir. 1996); See also SSR 85-28; SSR 86-8. 

Dr. Kerley was Plaintiff’s primary, if not exclusive, treating psychiatrist during the

period under adjudication and treated her extensively. Based on his clinical observations

and longitudinal picture of Plaintiff’s impairment, Dr. Kerley expressed doubt that Plaintiff

would be able to hold any job due to her inter-personal limitations. (Tr. 183.) Crediting

Dr. Kerley’s conclusions as a matter of law, the evidence establishes that Plaintiff’s

mental impairments were “severe” because she displayed at least “marked,” if not

“extreme,” limitations in her social functioning, including her ability to respond

appropriately to supervision and cooperate with coworkers. 20 C.F.R. app. 1, subpt. P,

12.00(C)(2) § 404. Moreover, Plaintiff also suffered from poor concentration and impaired

memory.7

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whether substantial evidence would support the Secretary’s denial of benefits if the

appropriate test had been applied). 

8 The ALJ indicates that Plaintiff’s mental health improved after she moved to Hong

Kong in the summer of 1995. Whether there was a cessation of disability at any point after

the initial 12-month period of disability, which would affect the amount of any benefits

awarded, is not an issue for this Court to decide. The issue before the Court is Plaintiff’s

eligibility for benefits. However, the Court notes that Plaintiff testified that she continued to

suffer from depression in Hong Kong and medicated herself. (Tr. 487-88.) After her return

to the United States, her various treating physicians unanimously concluded that she

suffered from severe major depressive disorder and personality disorders.

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In support of his finding of “non-severity,” the ALJ noted that the record did not

disclose a severe impairment lasting 12 continuous months as required by SSA

regulations. 20 C.F.R. § 404.1505(a). However, crediting Dr. Kerley’s opinion, Plaintiff’s

severe impairment lasted at least from January 31, 1994 until her final treatment with Dr.

Kerley on June 22, 1995. Under applicable law, the disability must last, or be expected to

last, at least 12 months beginning with the onset of disability. SSR 82-52. Plaintiff’s

alleged onset of disability was on January 31, 1994. Therefore, Plaintiff has satisfied the

duration requirement under step two.8

In sum, the ALJ failed to provide specific and legitimate reasons for rejecting Dr.

Kerley’s opinion, constituting reversible legal error. Edlund, 253 F.3d at 1160. By failing

to provide sufficient weight to that opinion, the ALJ’s conclusion that Plaintiff’s mental

impairment was “non-severe” lacked substantial evidentiary support in the record. 

Accordingly, the Court reverses and remands the matter to continue the sequential

evaluation at step three.

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V. CONCLUSION

For the reasons discussed above, Plaintiff’s motion for summary judgment is

GRANTED. Defendant’s cross-motion for summary judgment is DENIED. The decision

of the ALJ is reversed and this matter is remanded to the Commissioner to continue the

sequential evaluation process at step three. The Clerk shall enter judgment accordingly.

IT IS SO ORDERED.

DATED: December 12, 2006

Hon. Barry Ted Moskowitz

United States District Judge

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