Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-almd-3_12-cv-00411/USCOURTS-almd-3_12-cv-00411-0/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:405 Review of HHS Decision (SSID)

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IN THE UNITED STATES DISTRICT COURT

FOR THE MIDDLE DISTRICT OF ALABAMA

EASTERN DIVISION

JO ANN JACKSON, )

)

Plaintiff, )

)

v. ) CIVIL ACTION NO. 3:12cv411-WC

)

CAROLYN W. COLVIN, )

Acting Commissioner of Social Security,)

)

Defendant. )

MEMORANDUM OPINION

I. INTRODUCTION

Plaintiff, Jo Ann Jackson, applied for disability insurance benefits under Title II of 

the Social Security Act (“the Act”), 42 U.S.C. §§ 401 et seq, and supplemental security 

income (“SSI”) payments under Title XVI of the Act, 42 U.S.C. §§ 1381 et seq. Her

disability insurance benefits application was denied at the initial administrative level. 

Plaintiff then requested and received a hearing before an Administrative Law Judge 

(“ALJ”). Following the hearing, the ALJ issued a decision in which he found Plaintiff 

not disabled at any time through the date of the decision. Tr. 22. The Appeals Council 

rejected Plaintiff’s request for review of the ALJ’s decision. Tr. 1-5. The ALJ’s decision 

consequently became the final decision of the Commissioner of Social Security 

(“Commissioner”).1

 See Chester v. Bowen, 792 F.2d 129, 131 (11th Cir. 1986). The case 

 1 Pursuant to the Social Security Independence and Program Improvements Act of 1994, Pub. L. No. 103-

296, 108 Stat. 1464, the functions of the Secretary of Health and Human Services with respect to Social 

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is now before the court for review under 42 U.S.C. § 405(g). Pursuant to 28 U.S.C. § 

636(c), both parties have consented to the conduct of all proceedings and entry of a final 

judgment by the undersigned United States Magistrate Judge. Pl.’s Consent to 

Jurisdiction (Doc. 7); Def.’s Consent to Jurisdiction (Doc. 6). Based on the court’s 

review of the record and the briefs of the parties, the court AFFIRMS the decision of the 

Commissioner.

II. STANDARD OF REVIEW

Under 42 U.S.C. § 423(d)(1)(A), a person is entitled to disability benefits when 

the person is unable to

engage in any substantial gainful activity by reason of any medically 

determinable physical or mental impairment which can be expected to 

result in death or which has lasted or can be expected to last for a 

continuous period of not less than 12 months.

42 U.S.C. § 423(d)(1)(A).2

To make this determination, the Commissioner employs a five-step, sequential 

evaluation process. See 20 C.F.R. §§ 404.1520, 416.920 (2006).

(1) Is the person presently unemployed?

(2) Is the person’s impairment severe?

(3) Does the person’s impairment meet or equal one of the specific 

impairments set forth in 20 C.F.R. Pt. 404, Subpt. P, App. 1? [the Listing of 

Impairments]

(4) Is the person unable to perform his or her former occupation?

 

Security matters were transferred to the Commissioner of Social Security.

2 A “physical or mental impairment” is one resulting from anatomical, physiological, or psychological 

abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic 

techniques.

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(5) Is the person unable to perform any other work within the economy?

An affirmative answer to any of the above questions leads either to the next 

question, or, on steps three and five, to a finding of disability. A negative 

answer to any question, other than step three, leads to a determination of 

“not disabled.”

McDaniel v. Bowen, 800 F.2d 1026, 1030 (11th Cir. 1986).3

The burden of proof rests on a claimant through Step 4. See Phillips v. Barnhart, 

357 F.3d 1232, 1237-39 (11th Cir. 2004). A claimant establishes a prima facie case of 

qualifying disability once they have carried the burden of proof from Step 1 through Step 

4. At Step 5, the burden shifts to the Commissioner, who must then show there are a 

significant number of jobs in the national economy the claimant can perform. Id. 

To perform the fourth and fifth steps, the ALJ must determine the claimant’s 

Residual Functional Capacity (RFC). Id. at 1238-39. RFC is what the claimant is still 

able to do despite his impairments and is based on all relevant medical and other 

evidence. Id. It also can contain both exertional and nonexertional limitations. Id. at 

1242-43. At the fifth step, the ALJ considers the claimant’s RFC, age, education, and 

work experience to determine if there are jobs available in the national economy the 

claimant can perform. Id. at 1239. To do this, the ALJ can either use the Medical 

Vocational Guidelines4 (grids) or call a vocational expert (VE). Id. at 1239-40.

The grids allow the ALJ to consider factors such as age, confinement to sedentary 

or light work, inability to speak English, educational deficiencies, and lack of job 

 3 McDaniel v. Bowen, 800 F.2d 1026 (11th Cir. 1986), is a supplemental security income case (SSI). The 

same sequence applies to disability insurance benefits. Cases arising under Title II are appropriately cited 

as authority in Title XVI cases. See, e.g., Ware v. Schweiker, 651 F.2d 408 (5th Cir. 1981).

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experience. Each factor can independently limit the number of jobs realistically available 

to an individual. Phillips, 357 F.3d at 1240. Combinations of these factors yield a 

statutorily-required finding of “Disabled” or “Not Disabled.” Id. 

The court’s review of the Commissioner’s decision is a limited one. This Court 

must find the Commissioner’s decision conclusive if it is supported by substantial 

evidence. 42 U.S.C. § 405(g); Graham v. Apfel, 129 F.3d 1420, 1422 (11th Cir. 1997). 

“Substantial evidence is more than a scintilla, but less than a preponderance. It is such 

relevant evidence as a reasonable person would accept as adequate to support a 

conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971). See also Crawford v. 

Comm’r of Soc. Sec., 363 F.3d 1155, 1158 (11th Cir. 2004) (“Even if the evidence 

preponderates against the Commissioner’s findings, [a reviewing court] must affirm if the 

decision reached is supported by substantial evidence.”). A reviewing court may not look 

only to those parts of the record which support the decision of the ALJ, but instead must 

view the record in its entirety and take account of evidence which detracts from the 

evidence relied on by the ALJ. Hillsman v. Bowen, 804 F.2d 1179 (11th Cir. 1986). 

[The court must] . . . scrutinize the record in its entirety to determine the 

reasonableness of the [Commissioner’s] . . . factual findings. . . . No 

similar presumption of validity attaches to the [Commissioner’s] . . . legal 

conclusions, including determination of the proper standards to be applied 

in evaluating claims.

Walker v. Bowen, 826 F.2d 996, 999 (11th Cir. 1987). 

 4 See 20 C.F.R. pt. 404 subpt. P, app. 2.

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III. ADMINISTRATIVE PROCEEDINGS

Plaintiff was fifty years old at the time of the hearing before the ALJ. Tr. 138.

Plaintiff completed the eleventh grade. Tr. 147. Plaintiff’s past relevant work experience 

was as a “prep cook.” Tr. 143. Following the administrative hearing, and employing the 

five-step process, the ALJ found Plaintiff “has not engaged in substantial gainful activity 

since April 1, 2008, the amended onset date.” (Step 1) Tr. 32. At Step 2, the ALJ found 

that Plaintiff suffers from the following severe impairments: “depression; obesity; and 

substance abuse (in reported remission).” Id. The ALJ determined that Plaintiff’s 

allegation of carpal tunnel syndrome “is not medically determinable.” Id. The ALJ then 

found that Plaintiff “does not have an impairment or combination of impairments that 

meets or medically equals one of the listed impairments in 20 CFR Part 404, Subpart P, 

Appendix 1 (20 CFR 404.1520(d), 404.1525 and 404.1526, 416.920(d), 416.925 and 

416.926).” Tr. 33. Next, the ALJ found that Plaintiff:

has the residual functional capacity to perform medium work . . . except she 

is best suited for short, simple, 1 to 2 step tasks.

Tr. 34. The ALJ then concluded that Plaintiff “is capable of performing past relevant 

work as a prep cook which is medium, SVP2 work. This work does not require the 

performance of work-related activities precluded by the claimant’s residual functional 

capacity.” (Step 4) Tr. 36. Accordingly, the ALJ determined that Plaintiff “has not been 

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under a disability, as defined in the Social Security Act, from June 15, 2006, through the 

date of th[e] decision.” Tr. 36.

5

IV. PLAINTIFF’S CLAIMS

Plaintiff presents three issues for this court’s consideration in review of the ALJ’s 

decision: 1) whether “[t]he Commissioner’s decision should be reversed, because the 

ALJ’s RFC assessment is not supported by substantial evidence as there is no evidence 

on the record to explain the ALJ’s assessment of Plaintiff’s physical limitations”; 2) 

whether “[t]he Commissioner’s decision should be reversed, because the ALJ’s mental 

RFC determination also lacks substantial support in which to base an administrative 

decision”; and 3) whether “[t]he Commissioner’s decision should be reversed, because 

the ALJ failed to fulfill his duty to develop the record.” Pl.’s Br. (Doc. 12) at 3. The 

court will address each argument below.

V. DISCUSSION

A. Whether the ALJ’s RFC assessment is supported by substantial evidence.

Plaintiff’s first two arguments challenge the ALJ’s RFC determination, arguing 

that the RFC is not supported by substantial evidence as to either Plaintiff’s physical or 

mental limitations. 

At the administrative law judge hearing level, the ALJ is responsible for assessing 

a claimant’s RFC. 20 C.F.R. § 404.1546(c). The ALJ must assess a claimant’s RFC 

 5 This appears to be a typographical error as the ALJ’s opinion notes Plaintiff amended her 

alleged onset date at the hearing to April 1, 2008. Tr. 30; 4.

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“based on all of the relevant medical and other evidence[,]” and, in general, the claimant 

will be responsible for providing the evidence used to make a finding about the RFC. 20 

C.F.R. § 404.1545(a)(3). The United States Court of Appeals for the Eleventh Circuit 

has held that the ALJ’s RFC assessment may be supported by substantial evidence, even 

in the absence of an opinion from an examining medical source about Plaintiff’s 

functional capacity. See, e.g., Green v. Soc. Sec. Admin., 223 F. App’x 915, 923 (11th 

Cir. 2007) (unpublished opinion) (finding the ALJ’s RFC assessment supported by 

substantial evidence where he rejected treating physician’s opinion properly and 

formulated the plaintiff’s RFC based on treatment records, without a physical capacities 

evaluation by any physician); see also Dailey v. Astrue, 2012 WL 3206482, at *9 (S.D. 

Ala. July 18, 2012) (“an ALJ may reach an RFC determination in appropriate 

circumstances on a record that does not include an RFC opinion from a treating or 

examining medical source.” (citing Griffin v. Astrue, 2008 WL 4417228, at *10 (S.D. 

Ala. Sept. 23, 2008))).

The court finds that the ALJ’s RFC assessment is supported by the evidence of 

record in this case. As to Plaintiff’s physical RFC determination, Plaintiff argues that 

there are no medical opinions of record because “[t]he only opinions of record regarding 

Ms. Jackson’s remaining physical abilities despite her impairments are found at Exhibit 

6F (Tr. 334-341). Exhibit 6F, however, was completed by a Single Decisionmaker 

(SDM).” Pl.’s Br. (Doc. 12) at 4. The ALJ’s opinion notes that the conclusions of the

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SDM “also supported a finding of ‘not disabled.’” Tr. 35. However, the ALJ also noted 

that those physicians are non-examining and that while “their opinions do not as a general 

matter deserve as much weight as those of examining or treating physicians, those 

opinions do deserve some weight, particularly in a case like this in which there exist a 

number of other reasons to reach similar conclusions.” Tr. 35. Thus, the ALJ did not 

rely on the opinion of the SDM, but simply noted that it supported other medical opinions 

of record. The court finds no error in the ALJ’s analysis of the SDM’s opinion. See, e.g., 

Carter v. Astrue, 2012 WL 2135471, at *4 (M.D. Ala. June 13, 2012) (finding harmless 

error where an ALJ relied on a state agency RFC assessment he “acknowledge[d] . . . is 

that of a single decision-maker,” and to which the ALJ assigned “ ‘little weight’ to the 

extent that it differ[ed] from his own conclusions[,]” instead choosing to “assign[ ] 

‘greater weight to the treating and examining physician[s’] reports,” because “the ALJ’s 

express reasoning does not suggest that he ‘essentially adopted the State Agency RFC”) 

(citing Siverio v. Comm’r of Soc. Sec., 461 F. App’x 869 (11th Cir. 2012) (finding the 

ALJ’s reliance on SDM’s RFC assessment was not harmless error because “[t]he ALJ’s 

opinion shows not only that the ALJ labored under the mistaken belief that [the SDM]’s 

RFC assessment had been authored by a physician, but also that he gave [the SDM]’s 

RFC assessment ‘significant weight.’ The remaining record evidence does not provide 

substantial evidence for the finding that [the plaintiff] was capable of performing medium

work.”)); see also Stewart v. Astrue, 2012 WL 1969318, at *6 (E.D. Pa. May 31, 2012) 

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(“Even if there were a concern that the ALJ labored under the mistaken belief that the 

Physical RFC form at Exhibit 10F had been authored by a physician, the error would be 

harmless in light of the remaining record evidence providing substantial evidence for the 

finding that Stewart was capable of performing work at the light exertional level.”) 

(citing Siverio, 461 F. App’x at 871-72)).

Moreover, in evaluating Plaintiff’s physical limitations, the ALJ discussed a 

consultative examination performed by Dr. Popov in January 2010, stating that Dr. Popov 

opined that Plaintiff was:

well developed, well nourished, alert, does not appear acutely ill, not in 

acute distress, cooperative and well groomed. The respiratory and 

cardiovascular examinations were normal. The cervical spine exam was 

normal, and only minimal point tenderness was found in the lumbar exam. 

The SI joints showed full range of motion without point tenderness (Exhibit 

11F/6). The neurological exam was normal, except for 4/5 strength in all 

extremities. However, this was attributed to poor motivation during the 

exam (Exhibit 11F/7). While the claimant complained of carpal tunnel 

syndrome, no nerve conduction study has been performed, and Dr. Popov 

noted no problems with her upper extremities during the exam except for 

that previously noted. He noted the claimant was treated for depression 

which was poorly controlled. The physical diagnosis was unspecified 

backache, controlled, and carpal tunnel syndrome. 

Tr. 34-35 (emphasis in original). Dr. Popov also opined that “[a]ll [of Plaintiff’s] medical 

problems can effectively be treated.” Tr. 386. Dr. Popov also completed a Physical CE 

sheet, which the ALJ “discounted since they appear to be based solely on subjective 

claimant provided information, rather than on the objective findings.” Tr. 35. Indeed, 

Dr. Popov’s notes state that “Pt claims she can sit for 1 hr, stand 15’, walk 20 yards, does 

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not lift and carry since she was told not to(?) and can not travel [sic].” Tr. 386. 

Additionally, the ALJ noted “neither her treating physician nor the consultative examiner 

provided any credible work-related restrictions based on her physical complaints.” Tr. 

35. Based on this evidence, the ALJ limited Plaintiff to a “medium exertional level” of 

activity “[b]ased on the history of complain[t]s of back pain combined with obesity . . . to 

give the claimant every benefit of the doubt” and noted that “[t]here is a lack of any 

objective evidence, such as x-rays, to support any further reduction in the exertional 

level.” Tr. 35. Thus, the court finds there was sufficient evidence on the record for the 

ALJ to determine Plaintiff’s physical RFC. 

As to Plaintiff’s mental RFC, this too is supported by substantial evidence. 

“Agency regulations require the ALJ to use the ‘special technique’ dictated by the PRTF 

[Psychiatric Review Technique Form] for evaluating mental impairments.” Moore v. 

Barnhart, 405 F.3d 1208, 1213 (11th Cir. 2005) (citing 20 C.F.R. § 404.1520a-(a)). 

“This technique requires separate evaluations on a four-point scale of how the claimant’s 

mental impairment impacts four functional areas: ‘activities of daily living; social 

functioning; concentration, persistence, or pace; and episodes of decompensation.’” Id. 

(quoting 20 C.F.R. § 404.1520a-(c)(3-4)). The ALJ is required “to complete a PRTF and 

append it to the decision, or incorporate its mode of analysis into his findings and 

conclusions. Failure to do so requires remand.” Id. at 1214 (citing other circuits for this 

holding). In this case, there is a PRTF form on the record, completed by Dr. Estock, and 

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while the ALJ does not address the form specifically, he did evaluate Plaintiff on all four 

functional areas and, thus, he did “incorporate its mode of analysis into his findings and 

conclusions.” See, e.g., Bentley v. Astrue, 2008 WL 4498963, at *4 (M.D. Ga. Sept. 30, 

2008 (finding no error where “although the ALJ did not complete a PRTF, he did analyze 

and incorporate the PRTF’s mode of analysis into his decision.”). In this case, the ALJ 

found that Plaintiff has: 1) “mild restriction” in activities of daily living; 2) “moderate

difficulties” in social functioning; 3) “moderate difficulties” with regard to concentration, 

persistence, or pace; and 4) experienced no episodes of decompensation of extended 

duration. Tr. 33 (emphasis added). The ALJ incorporated Plaintiff’s mental restrictions, 

limiting her to “unskilled” work “[b]ased on her history of mental health treatment” and 

“short, simple, 1 to 2 step tasks.” Tr. 34-35. 

In challenging the ALJ’s mental RFC assessment, Plaintiff contends that “the nonexamining opinions of record expressed by Dr. Estock do not provide substantial 

support” and that because “the evidentiary record contains additional significant 

treatment from East Alabama Mental Health including 14 progress notes,” then “the ALJ 

should have either requested Ms. Jackson’s treating psychiatrist to express medical 

opinions or obtained an updated medical source opinion from an examining source.” 

Pl.’s Br. (Doc. 12) at 7. However, Plaintiff fails to allege what, if any, further limitations 

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are contained in these additional notes that are not accounted for in the ALJ’s 

assessment.6

 Thus, this argument lacks merit.

Finally, in determining Plaintiff’s RFC, the ALJ evaluated Plaintiff’s credibility, 

noting that while, in October 2008, Plaintiff told her mental health provider she had been 

clean for 9 years, her testimony reflected she had only been off cocaine a number of 

months at that time. The ALJ, thus, determined this inconsistency “serves to diminish the 

credibility of the claimant’s allegations.” Tr. 35. The ALJ also noted Plaintiff’s 

noncompliance with medications (Exs. 8F at 10 & 13F at 7). 

Accordingly, upon review of the record, the court finds that the ALJ’s RFC is 

supported by substantial evidence and Plaintiff’s argument lacks merit. 

B. Whether the ALJ failed to fulfill his duty to develop the record.

Next, Plaintiff argues that the ALJ failed in his duty to develop a full and fair 

record because he did not order objective medical testing to establish that Plaintiff suffers 

from carpal tunnel syndrome. Pl.’s Br. (Doc. 12) at 8. Plaintiff argues as follows:

Despite the fact that Dr. Popov provided a diagnostic impression of 

aggravated carpal tunnel syndrome based upon his personal examination, 

the ALJ simply dismissed Ms. Jackson’s carpal tunnel syndrome because 

“no nerve conduction study had been performed” (Tr. 35, 386). Before 

dismissing Ms. Jackson’s carpal tunnel syndrome, however, the ALJ had a 

 6 Dr. Estock completed both a Psychiatric Review Technique form and Mental RFC form in February 

2009. Tr. 362-79. In the Psychiatric Review Technique form Dr. Estock opined Plaintiff has: 1) “mild

restriction” in activities of daily living; 2) “moderate difficulties” in social functioning; 3) “mild

difficulties” with regard to concentration, persistence, or pace; and 4) experienced no episodes of 

decompensation of extended duration. Tr. 372 (emphasis added). Thus, the ALJ’s evaluation, which 

found moderate limitations in two areas, is actually more restrictive than Dr. Estock. 

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duty to develop the record by obtaining such objective studies so as to 

allow himself to make an informed decision.

Pl.’s Br. (Doc. 12) at 8 (emphasis in original). 

“[R]egardless of whether a claimant is represented by counsel, the ALJ ‘has a duty 

to develop a full and fair record.’” George v. Astrue, 338 F. App’x 803, 805 (11th Cir. 

2009) (citing Brown v. Shalala, 44 F.3d 931, 934 (11th Cir. 1995)). Remand is not 

required, however, unless the administrative record as a whole is “inadequate or 

incomplete or ‘show[s] the kind of gaps in the evidence necessary to demonstrate 

prejudice.’” George, 338 F. App’x at 805 (citing Graham v. Apfel, 129 F.3d 1420, 1423 

(11th Cir. 1997)). “Even though Social Security courts are inquisitorial, not adversarial, 

in nature, claimants must establish that they are eligible for benefits. The administrative 

law judge has a duty to develop the record where appropriate but is not required to order 

a consultative examination as long as the record contains sufficient evidence for the 

administrative law judge to make an informed decision.” Ingram v. Comm’r of Soc. Sec. 

Admin, 496 F.3d 1253, 1269 (11th Cir. 2007) (emphasis added) (citing Doughty v. Apfel,

245 F.3d 1274, 1281 (11th Cir. 2001)). “The regulations do not require the 

Commissioner to secure a consultative evaluation, nor do they create a right to a 

consultative examination.” Pike v. Astrue, 2012 WL 2930780, at *5 (M.D. Ala. July 18, 

2012).

The record in this case does not support Plaintiff’s contention that the ALJ failed 

to develop the record by not ordering carpal tunnel testing. At the hearing, Plaintiff 

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testified that Dr. Atassi diagnosed carpal tunnel in both of her hands and told her she 

needs surgery, but that he could not recommend the surgery due to her lack of medical 

insurance. Tr. 8. However, no medical records support this statement. The medical 

records from the Goodwater Clinic simply state “CTS – splint, refer.” Tr. 227. Thus, the 

court finds the ALJ did not err in finding that “there is no support, other than claimant’s 

oral history, regarding carpal tunnel syndrome, and this finding is discounted.” Tr. 35. 

Moreover, the court notes that there already was a consultative examination—

performed by Dr. Popov in 2010—on the record before the ALJ. Dr. Popov’s written 

opinion discussed Plaintiff’s carpal tunnel syndrome by noting “Pt told by an MD 2 1/2 

yrs ago that she had R CTS. No nerve cond. study was done. Pt did not follow up with 

doctor but continues to wear a wrist brace during the day. Pt advised to take off the brace 

during the day and have follow up done with the M.” Tr. 386. A review of Dr. Popov’s 

notes suggests his “diagnosis” of “carpal tunnel syndrome - aggravated” reflects 

Plaintiff’s self-reported complaints rather than his own diagnostic impression. This is 

most evident in the fact that Dr. Popov’s medical recommendations do not discuss 

Plaintiff’s carpal tunnel syndrome. The ALJ discussed and considered Dr. Popov’s 

medical opinion, as described above, and discounted Plaintiff’s allegations with respect 

to her carpal tunnel syndrome. Thus, there was nothing further for the ALJ to do in 

developing the record with respect to Plaintiff’s carpal tunnel syndrome. 

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VI. CONCLUSION

The court has carefully and independently reviewed the record and concludes that, 

for the reasons given above, the decision of the Commissioner is AFFIRMED. A 

separate judgment will issue.

Done this 27th day of September, 2013.

/s/ Wallace Capel, Jr.

WALLACE CAPEL, JR.

UNITED STATES MAGISTRATE JUDGE

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