Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alnd-3_15-cv-01355/USCOURTS-alnd-3_15-cv-01355-0/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 (SSID)

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IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF ALABAMA

NORTHWESTERN DIVISION

JENNIFER LYNN PLEASANT,

 Plaintiff,

 vs.

CAROLYN W. COLVIN,

Commissioner of Social Security,

 Defendant.

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Case No. 3:15-cv-01355-TMP

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MEMORANDUM OPINION

I. Introduction

The plaintiff, Jennifer Lynn Pleasant, appeals from the decision of the 

Commissioner of the Social Security Administration (“Commissioner”) denying 

her application for a period of disability and Disability Insurance Benefits (“DIB”) 

and Supplemental Security Income (“SSI”). Ms. Pleasant timely pursued and 

exhausted her administrative remedies and the decision of the Commissioner is 

ripe for review pursuant to 42 U.S.C. §§ 405(g), 1383(c)(3).

Ms. Pleasant was forty years old on her alleged onset date, and she has the 

equivalent of a high school education. (Tr. at 29). Her past work experience 

FILED

 2016 Aug-15 AM 11:22

U.S. DISTRICT COURT

N.D. OF ALABAMA

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includes employment as a chicken processing plant worker, salad bar attendant, 

cook, and shift manager at a fast-food restaurant. (Tr. at 28). Ms. Pleasant claims 

that she became disabled on April 19, 2011, due to fibromyalgia, scoliosis in her 

upper back, diabetes, high blood pressure, acid reflux, anemia, high cholesterol, 

fluid on her left knee, chostochonritis, and bursitis in her left shoulder. (Tr. at 

149).1

When evaluating the disability of individuals over the age of eighteen, the 

regulations prescribe a five-step sequential evaluation process. See 20 C.F.R. 

§§ 404.1520, 416.920; see also Doughty v. Apfel, 245 F.3d 1274, 1278 (11th Cir. 

2001). The first step requires a determination of whether the claimant is “doing 

substantial gainful activity.” 20 C.F.R. §§ 404.1520(a)(4)(i), 416.920(a)(4)(i). If 

she is, the claimant is not disabled and the evaluation stops. Id. If she is not, the 

Commissioner next considers the effect of all of the physical and mental 

impairments combined. 20 C.F.R. §§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii). These 

impairments must be severe and must meet the durational requirements before a 

claimant will be found to be disabled. Id. The decision depends on the medical 

evidence in the record. See Hart v. Finch, 440 F.2d 1340, 1341 (5th Cir. 1971). If 

the claimant’s impairments are not severe, the analysis stops. 20 C.F.R. 

 1 It should be noted that the Claimant did not list depression or anxiety on her Adult Disability 

Report among the list of medical conditions limiting her ability to work. (Tr. at 149).

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§§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii). Otherwise, the sequential analysis 

continues to step three, which is a determination of whether the claimant’s 

impairments meet or equal the severity of an impairment listed in 20 C.F.R. Part

404, Subpart P, Appendix 1. 20 C.F.R. §§ 404.1520(a)(4)(iii), 416.920(a)(4)(iii).

If the claimant’s impairments fall within this category, she will be found disabled 

without further consideration. Id. If they do not, a determination of the claimant’s 

residual functional capacity will be made and the analysis proceeds to the fourth 

step. 20 C.F.R. §§ 404.1520(e), 416.920(e). Residual functional capacity 

(“RFC”) is an assessment, based on all relevant evidence, of a claimant’s 

remaining ability to do work despite his or her impairments. 20 C.F.R. 

§ 404.945(a)(1).

The fourth step requires a determination of whether the claimant’s 

impairments prevent her from returning to past relevant work. 20 C.F.R. 

§§ 404.1520(a)(4)(iv), 416.920(a)(4)(iv). If the claimant can still do her past 

relevant work, the claimant is not disabled and the evaluation stops. Id. If the 

claimant cannot do past relevant work, then the analysis proceeds to the fifth step. 

Id. Step five requires the court to consider the claimant’s RFC, as well as the 

claimant’s age, education, and past work experience, in order to determine if she 

can do other work. 20 C.F.R. §§ 404.1520(a)(4)(v), 416.920(a)(4)(v). If the 

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claimant can do other work, the claimant is not disabled. Id. The burden is on the 

Commissioner to demonstrate that other jobs exist which the claimant can 

perform; and, once that burden is met, the claimant must prove her inability to 

perform those jobs in order to be found disabled. Jones v. Apfel, 190 F.3d 1224, 

1228 (11th Cir. 1999).

Applying the sequential evaluation process, the ALJ determined that Ms. 

Pleasant has not engaged in substantial gainful activity since the alleged onset of her

disability in 2011. (Tr. at 23). According to the ALJ, Plaintiff’s fibromyalgia with 

chronic pain syndrome, coronary artery disease status post-stent placement, 

hypertension, diabetes mellitus, and obesity are considered “severe” based on the 

requirements set forth in the regulations. (Id.) The plaintiff also suffers from nonsevere impairments of mild scoliosis, gastroesophageal reflux disease (“GERD”), 

hyperlipidemia, anemia, depression, and anxiety. (Tr. at 24). However, the ALJ

found that these impairments neither meet nor medically equal any of the listed 

impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (Tr. at 25). Although 

the ALJ found that her medical conditions were of the type that one could 

reasonably expect to cause pain, he determined that Ms. Pleasant’s claims 

regarding the intensity and limiting effects of her impairments were not fully 

credible. (Tr. at 28). He determined that the plaintiff had the RFC to perform 

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“the full range of sedentary work, as defined in 20 CFR 404.1567(a) and 

416.967(a).” (Tr. at 26). 

According to the ALJ, Ms. Pleasant is unable to perform any of her past 

relevant work. (Tr. at 28). The plaintiff is a younger individual, has the equivalent 

of a high school education, and is able to communicate in English, as those terms 

are defined by the regulations. (Tr. at 29). The ALJ determined that 

transferability of job skills is not material to the determination of the plaintiff’s 

case. (Id.) The ALJ determined that there are a significant number of jobs in the 

national economy that the plaintiff is capable of performing and “considering the 

claimant’s age, education, and work experience, a finding of ‘not disabled’ is 

directed by Medical-Vocational Rule 201.28.” (Tr. at 29). The ALJ concluded 

his findings by stating that the plaintiff “has not been under a disability, as defined 

in the Social Security Act, from April 19, 2011,” to January 2, 2014, the date of the 

ALJ’s decision. (Tr. at 29-30).

II. Standard of Review

This court’s role in reviewing claims brought under the Social Security Act 

is a narrow one. The scope of its review is limited to determining (1) whether there 

is substantial evidence in the record as a whole to support the findings of the 

Commissioner, and (2) whether the correct legal standards were applied. See 

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Richardson v. Perales, 402 U.S. 389, 390, 401 (1971); Wilson v. Barnhart, 284 F.3d 

1219, 1221 (11th Cir. 2002). The court approaches the factual findings of the 

Commissioner with deference, but applies close scrutiny to the legal conclusions.

See Miles v. Chater, 84 F.3d 1397, 1400 (11th Cir. 1996). The court may not decide 

facts, weigh evidence, or substitute its judgment for that of the Commissioner. Id.

“The substantial evidence standard permits administrative decision makers to act 

with considerable latitude, and ‘the possibility of drawing two inconsistent 

conclusions from the evidence does not prevent an administrative agency’s finding 

from being supported by substantial evidence.’” Parker v. Bowen, 793 F.2d 1177, 

1181 (11th Cir. 1986) (Gibson, J., dissenting) (quoting Consolo v. Federal Mar. 

Comm’n, 383 U.S. 607, 620 (1966)). Indeed, even if this court finds that the 

evidence preponderates against the Commissioner’s decision, the court must 

affirm if the decision is supported by substantial evidence. Miles, 84 F.3d at 1400.

No decision is automatic, however, for “despite this deferential standard [for 

review of claims] it is imperative that the Court scrutinize the record in its entirety 

to determine the reasonableness of the decision reached.” Bridges v. Bowen, 815 

F.2d 622, 624 (11th Cir. 1987). Moreover, failure to apply the correct legal 

standards is grounds for reversal. See Bowen v. Heckler, 748 F.2d 629, 635 (11th Cir. 

1984).

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The court must keep in mind that opinions such as whether a claimant is 

disabled, the nature and extent of a claimant’s residual functional capacity, and the 

application of vocational factors “are not medical opinions, . . . but are, instead, 

opinions on issues reserved to the commissioner because they are administrative 

findings that are dispositive of a case; i.e., that would direct the determination or 

decision of disability.” 20 C.F.R. §§ 404.1527(e), 416.927(d). Whether the 

plaintiff meets the listing and is qualified for Social Security disability benefits is a 

question reserved for the ALJ, and the court “may not decide facts anew, reweigh 

the evidence, or substitute [its] judgment for that of the Commissioner.” Dyer v. 

Barnhart, 395 F.3d 1206, 1210 (11th Cir. 2005). Thus, even if the court were to 

disagree with the ALJ about the significance of certain facts, the court has no power 

to reverse that finding as long as there is substantial evidence in the record

supporting it. 

III. Discussion

The Claimant asserts two grounds for reversal of the ALJ’s decision. Ms. 

Pleasant argues that the ALJ’s decision should be reversed and remanded because 

the ALJ erred in not determining that the plaintiff’s anxiety and depression were 

“severe” impairments at step two of the sequential analysis. She also argues that 

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the ALJ had a duty to expand the record if he had any questions regarding the 

plaintiff’s anxiety and depression. 

A. Severe Impairments

In addition to the other medical conditions identified by her, the plaintiff 

claims that she suffers from anxiety and depression, which have been treated with 

medication in the past, and that these impairments should have been designated 

“severe” by the ALJ. The ALJ addressed the plaintiff’s claims of anxiety and 

depression as follows:

The undersigned recognizes that there is some evidence of mental 

health problems in the record (Exhibits 14F and 15F). It appears that 

the claimant has been treated for depression and anxiety by her 

primary care provider with Valium and Ambien. The claimant is 

prescribed Cymbalta for fibromyaligia symptoms as opposed to mental 

health symptoms. There is no evidence of psychiatric hospitalization. 

In July 2013, the claimant contacted Lakeview Center complaining of 

symptoms of depression and anxiety. On August 1, 2013, she had an 

assessment screening by Donna Englehart, MS, LMHC (Licensed 

Mental Health Counselor), who is not an acceptable medical source 

under our regulations. Based entirely upon the claimant’s subject [sic]

account of her symptoms during an interview and mental status 

examination, Ms. Englehart assessed the claimant with bipolar 

disorder, most recent episode depressed, severe, with psychotic 

features. She found a Global Assessment of Functioning of 48, 

meaning moderately severe symptoms and impairments. The 

claimant was encourage [sic] to have counseling, but declined to do so.

Ms. Englehart’s findings are not consistent with or supported by the 

record as a whole, which includes no other evidence of mental health 

treatment other than routine and conservative treatment by the 

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claimant’s primary care provider and no diagnosis of bipolar disorder 

by an acceptable medical source. The claimant submitted an 

October 13, 2012 Function Report, which indicated no limitations 

related to mental health symptoms (Exhibit 4E). Giving the claimant 

the benefit of doubt, the undersigned has considered depression and 

anxiety as non-severe impairments. These impairments have not 

caused more than minimal limitation in the claimant’s ability to 

perform basic mental work activities. In making this finding, the 

undersigned has considered the four broad functional areas set out in 

the disability regulations for evaluating mental disorders and in section 

12.00C of the Listing of Impairments (20 CFR, Part 404, Subpart P, 

Appendix 1). These four broad functional areas are known as the 

“paragraph B” criteria. The first functional area is activities of daily 

living. In this area, the claimant has no limitation. The next 

functional area is social functioning. In this area, the claimant has no 

limitation. The third functional area is concentration, persistence, or 

pace. In this area, the claimant has no limitation. The fourth 

functional area is episodes of decompensation. In this area, the 

claimant has experienced no episodes of decompensation which have 

been of extended duration.

Because the claimant’s medically determinable mental impairments 

cause no more than “mild” limitation in any of the first three 

functional areas and “no” episodes of decompensation which have 

been of extended duration in the fourth area, they are non-severe (20 

CFR 404.1520a(d)(1) and 416.920a(d)(1)). The limitations identified 

in the “paragraph B” criteria are not a residual functional capacity 

assessment but are used to rate the severity of mental impairments at 

steps 2 and 3 of the sequential evaluation process. The mental 

residual functional capacity assessment used at steps 4 and 5 of the 

sequential evaluation process requires a more detailed assessment by 

itemizing various functions contained in the broad categories found in 

paragraph B of the adult mental disorders listings in 12.00 of the 

Listing of Impairments (SSR 96-8p). Therefore, the following residual 

functional capacity assessment reflects the degree of limitation the 

undersigned has found in the “paragraph B” mental function analysis.

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(Tr. at 24-25).

The treatment of the plaintiff for depression and anxiety is addressed 

intermittently throughout her medical records. However, when applying for DIB 

and SSI, the plaintiff did not allege that anxiety or depression impaired her ability 

to work. (Tr. at 62). The disability report, which specifically directed the plaintiff 

to “[l]ist all of the physical or mental conditions (including emotional or learning 

problems) that limit your ability to work,” failed to list any mental impairments. 

(Tr. at 148-49). When the plaintiff completed her list of medications, she stated 

that she was prescribed Valium “to help sleep,” and that she was prescribed 

Cymbalta to treat her fibromyalgia, not for the treatment or depression or anxiety. 

(Tr. at 152). When the plaintiff completed the disability report for her appeal, she 

listed “problems with my sciatica causing numbness in left leg” as the only change 

in her illnesses or conditions. (Tr. at 168). The plaintiff did not include Valium on 

her appeals medication list, and again stated that she was on Cymbalta as treatment

for fibromyalgia. (Tr. at 170).

The plaintiff’s medical records from Shoals Hospital on October 31, 2010, 

note her past medical history as diabetes, hypertension, previous Caesarian

Section, cholecystectomy, and ventral hernia repair. (Tr. at 223). The medications

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reported do not include anxiety or depression medications. (Id.) Later, records 

from Rheumatology Associates of North Alabama, P.C. note that she had been 

diagnosed with fibromyalgia and that she was prescribed Cymbalta for treatment of 

fibromyalgia. (Tr. at 259). The plaintiff’s Baptist Hospital triage sheet from 

September 26, 2011, does not note anxiety or depression on her medical history, 

and her records from Baptist Hospital on October 10, 2011,2 listed depression, but 

not anxiety as part of the plaintiff’s medical history. (Tr. at 275, 279, 280).

Medical records from Escambia Community Clinics dated September 12, 

2011, state that the plaintiff was prescribed Cymbalta, but not Valium. (Tr. at 315). 

Records from The Cardiovascular Institute of the Shoals dated May 31, 2011, 

indicate that the plaintiff was negative for anxiety, depression, memory change, and 

bipolar disorder. (Tr. at 324-25). Her medications included Cymbalta, but not 

Valium. (Tr. at 325). The plaintiff’s emergency room records from North Baldwin 

Hospital dated February 23, 2012, indicate that the plaintiff had a normal mood and 

affect and that she was negative for anxiety and depression. (Tr. at 343). The 

notations regarding depression, anxiety, and mood were the same in the plaintiff’s 

North Baldwin Records from December 12, 2011; July 7, 2012; August 31, 2012; 

October 15, 2012; November 7, 2012; and December 8, 2012. (Tr. at 340, 345, 356, 

 2

 The date is only partially legible.

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386, 398, 442). Finally, the plaintiff’s North Baldwin Hospital emergency room 

records from December 17, 2012, appear to indicate a history of anxiety, but also 

note that the plaintiff’s mood and affect were normal at the time of treatment. (Tr. 

at 428-29).

The plaintiff’s discharge summary from Thomas Hospital on August 1, 2011, 

makes no mention of depression or anxiety. (Tr. at 475-77). Her “active 

medication list” from the same date does not list Cymbalta, Valium, or similar 

medications. (Tr. at 503). The plaintiff’s December 20, 2012, medical records 

from Thomas Hospital indicate that the plaintiff was not currently, nor had she

ever been, treated for an emotional or behavioral disorder. (Tr. at 617). The 

records noted that the plaintiff did not have a complaint or diagnosis relating to 

emotional or behavioral disorders, had not ever had thoughts of harming herself, 

and did not currently have thoughts of harming herself. (Tr. at 618). Her 

medications list from that date includes Cymbalta, but not Valium or other 

depression or anxiety medications. (Tr. at 624-26).

The plaintiff’s records from Franklin Primary Health Center dated 

December 31, 2012, state that the plaintiff suffers from chronic depression. (Tr. at 

629, 631). Later, however, the records state that the plaintiff is positive for anxiety 

but negative for depression. (Tr. at 630). The plaintiff was admitted to West 

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Florida Healthcare on April 27, 2013. (Tr. at 719). Her medical history included 

anxiety with depression. (Tr. at 720). The plaintiff’s April 29, 2013, discharge 

report does not list depression or anxiety as a diagnosis, but does list Zoloft as one 

of the plaintiff’s medications. (Tr. at 648-49). The plaintiff’s June 20, 2013, 

records from Escambia Community Clinics note that the plaintiff suffers with 

anxiety and has been taking Valium to treat it. (Tr. at 655). 

The plaintiff was assessed by Donna Englehart, MS, LMHC, at Lakeview 

Center Baptist Health Care on July 17, 2013. (Tr. at 668). The plaintiff arrived at 

the office complaining of depression, anxiety, and agitation. (Id.) The records 

further state that she was suffering from mood and psychotic disorders, and her key 

symptoms were anhedonia, hopelessness, anxiety, and panic, and that the plaintiff 

had a history of suicide attempts.3

 (Tr. at 669). The plaintiff was not experiencing 

current suicidal ideation, and her risk level was determined to be low. (Tr. at 670). 

Englehart diagnosed the plaintiff with bipolar disorder along with severe depression 

with psychotic feature and anxiety disorder. 

Although the plaintiff, relying heavily on Englehart’s diagnosis, contends 

that the plaintiff’s anxiety and depression causes “more than a minimal limitation 

of the claimant’s ability to perform basic mental work activities” (doc. 6), the 

 3

 It was clarified that the plaintiff “tried overdosing as a teenager but no hospitalizations are 

reported.” (Tr. at 672).

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argument is not consistent with the record as a whole. The plaintiff did not allege 

that her anxiety or depression are reasons that she is unable to work, and, she did 

not testify to such at the ALJ’s hearing. Except for the evaluation by Englehart, the 

plaintiff’s medical records do not indicate that the plaintiff complained to her 

doctors that her anxiety or depression were unmanageable or had a significant

impact on her ability to perform work or life activities. 

The weight to be afforded a medical opinion regarding the nature and 

severity of a claimant’s impairments depends, among other things, upon the 

examining and treating relationship the medical source had with the claimant, the 

evidence the medical source presents to support the opinion, how consistent the 

opinion is with the record as a whole, and the specialty of the medical source. See 

20 C.F.R. §§ 404.1527(d), 416.927(d). Furthermore, “good cause” exists for an 

ALJ not to give a treating physician’s opinion substantial weight when the: “(1) 

treating physician’s opinion was not bolstered by the evidence; (2) evidence 

supported a contrary finding; or (3) treating physician’s opinion was conclusory or 

inconsistent with the doctor’s own medical records.” Phillips v. Barnhart, 357 F.3d 

1232, 1241 (11th Cir. 2004) (citing Lewis, 125 F.3d at 1440); see also Edwards v. 

Sullivan, 937 F.2d 580, 583-84 (11th Cir. 2004) (holding that “good cause” existed 

where the opinion was contradicted by other notations in the physician’s own 

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record). Any medical source’s opinion can be rejected where the evidence 

supports a contrary conclusion. See, e.g., McCloud v. Barnhart, 166 Fed. App’x 410, 

418-19 (11th Cir. 2008). The ALJ clearly addressed his reasoning for not giving 

greater weight to Englehart’s opinion. The court is of the opinion that the ALJ had 

good cause to disregard Englehart’s assessment of the plaintiff, and to find that the 

plaintiff’s depression and anxiety were non-severe impairments. See Phillips, 357 

F.3d at 1240-41.4

B. Duty to Expand the Record

The plaintiff argues that, “[a]t the very least, the ALJ had a duty to fully 

develop the record, which in this case would include ordering a psychological 

consultative examination.” (Doc. 10, p. 8). The ALJ’s duty to develop the record 

is not triggered when the record contains sufficient evidence to make an informed 

decision. Ingram v. Commissioner of Social Security, 496 F.3d 1253, 1269 (11th Cir. 

2007). The Eleventh Circuit has determined that a consultative examination must 

be ordered if one is needed to make an informed decision regarding the claimant’s 

disability. Reeves v. Heckler, 734 F.2d 519, 522 n.1 (11th Cir. 1984), citing Ford v. 

Secretary of Health and Human Servs., 659 F.2d 66, 69 (5th Cir. 1981) (Unit B). An 

 4 To the extent that the plaintiff argues that the ALJ erred at step two of the sequential analysis, 

it is clear that he found that she suffered from severe impairments (if not including anxiety and 

depression) and the analysis proceeded to the next step. The finding of a severe impairment,

allowing the sequential analysis to proceed to step three, moots any concern about the 

assessment of the severity or non-severity of impairments at that stage of the analysis. 

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ALJ may request a consultative examination “to secure needed medical evidence, 

such as clinical findings, laboratory tests, a diagnosis, or prognosis” if the record 

indicates “a change in [the claimant’s] condition that is likely to affect [the 

claimant’s] ability to work, but the current severity of [the claimant’s] impairment 

is not established.” 20 C.F.R. § 404.1519a(b)(4). 

However, if the record is sufficiently developed for the ALJ to make a 

determination, it is not necessary for the ALJ to order an additional consultative 

examination or to expand the record. Good v. Astrue, 240 Fed. Appx. 399, 403-404 

(11th Cir. 2007). In the instant case, the ALJ had available to him years of the 

plaintiff’s medical records as well as disability reports completed by the plaintiff 

and the plaintiff’s own testimony. The record was sufficiently developed to allow 

the ALJ to determine which of the plaintiff’s impairments are severe without 

seeking an additional consultative examination or further information from 

Englehart. 

IV. Conclusion

The ALJ’s determination is supported by substantial evidence and was both 

comprehensive and consistent with the applicable SSA rulings. Upon review of the 

administrative record, and considering all of Ms. Pleasant’s arguments, the 

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Commissioner’s decision is due to be and hereby is AFFIRMED and the action is 

DISMISSED WITH PREJUDICE.

DONE this 15th day of August, 2016.

_______________________

T. MICHAEL PUTNAM

UNITED STATES MAGISTRATE JUDGE

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