Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-4_06-cv-00363/USCOURTS-azd-4_06-cv-00363-0/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:416 Denial of Social Security Benefits

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IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Connie McClintock, )

) NO. CV06-363-TUC-JMR (JM)

Plaintiff, )

) REPORT AND RECOMMENDATION

v. )

)

)

Michael J. Astrue, )

Commissioner of Social Security, )

) 

Defendant. ) )

Pursuant to 42 U.S.C. § 405(g), Plaintiff Connie McClintock seeks judicial review of

a final decision by the Commissioner of Social Security ("Commissioner") denying her

benefits. This Social Security Appeal has been referred to the United States Magistrate

Judge pursuant to Local Rule – Civil 72.2(a)(10) of the Rules of Practice of this Court.

Based on the pleadings of the parties and the record submitted to the Court, the Magistrate

Judge recommends that the District Court, after its independent review, grant in part and

deny in part Plaintiff's Motion for Summary Judgment [Doc. No. 16] and grant in part and

deny in part Defendant's Cross-Motion for Summary Judgment [Doc. No. 19].

I. Procedural Background 

McClintock first applied for Supplemental Security Income (“SSI”) in 1974. (Tr. 23).

Applications filed in 1974 and 1975 were denied at the initial stage and McClintock sought

no further review. (Tr. 23). McClintock then received Child’s Insurance Benefits (“CIB”)

on behalf of her daughter until 1977 when her daughter was no longer eligible. (Tr. 23).

McClintock subsequently applied for SSI in March 1986, alleging disability since 1980. (Tr.

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22, 699). McClintock’s applications were ultimately denied by an administrative law judge

(“ALJ”) in 1988. (Tr. 699). 

McClintock filed her current applications in 1995. She filed for CIB on behalf of

herself, alleging disability since the day she was born, November 18, 1958. (Tr. 4, 22, 179-

81). She also filed a claim for SSI alleging disability since July 1992. (Tr. 704). Following

a hearing (Tr. 658-81), McClintock’s applications were denied by ALJ F.H. Ayer in

December 1997. (Tr. 22, 70-82). The Appeals Council granted McClintock’s request for

review and another hearing was held in November 2001. (Tr. 137-39 & 682-95). Another

unfavorable decision was issued by ALJ Frederick J. Graf on January 25, 2002. (Tr. 90-99).

The Appeals Council vacated the decision, however, because the claim file had been lost and

the Council was therefore unable to determine whether the ALJ’s decision had been

supported by substantial evidence. (Tr. 175-76 & 699-700). 

A final hearing was held on May 3, 2004. (Tr. 696-715). McClintock was

represented by counsel and testified on her own behalf. During the hearing she withdrew her

application for CIB. (Tr. 700). Following the hearing, ALJ Graf once again issued a

decision finding hat McClintock was not disabled. (Tr. 22-35). McClintock’s request for

review by the Appeals Council was denied and the decision became the final decision of the

Commissioner. (Tr. 11-14). 

McClintock subsequently filed her complaint in this case seeking judicial review of

the ALJ's decision pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). In her motion for

summary judgment, McClintock asserts that the ALJ failed to properly analyze her

credibility, ignored evidence of her motivations to work and the impairments that prevented

her from doing so, improperly drew a negative inference from her failure to comply with

medical treatment, improperly evaluated her RFC, failed to call the required Vocational

Expert, and improperly found her not disabled. Plaintiff’s Memorandum, pp. 1-12. In terms

of relief, McClintock seeks an order awarding benefits.

In the response and cross-motion, the Commissioner argues that the ALJ properly

assessed McClintock’s RFC and credibility, and properly relied on the Medical-Vocational

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Guidelines. Defendant’s Brief, pp. 1-8. Alternatively, the Commissioner requests that this

matter be remanded for further consideration by the ALJ.

II. Record on Review

A. Relevant Examination and Treatment Records

McClintock was 45 years old at the time ALJ Frederick Graf issued his decision. (Tr.

35). She competed eighth grade and has never held a job long enough for it to qualify as

substantial gainful activity or past relevant work. (Tr. 23, 35).

From 1992 through 1995, McClintock treated with R.L. Goedecke, D.O., for headaches ,

sleep problems and pre- and post-natal care. (Tr. 360-372). In May 1995, Dr. Goedecke completed

a form for the Arizona Department of Economic Security (“DES”) indicating that McClintock was

unable to work for three months due to migraine headaches, congenital cataracts and a hiatal hernia.

(Tr. 359). 

On August 12, 1995, David Taylor, M.D., from the DES Disability Determination Service

(“DDS”), issued a report after examining McClintock. (Tr. 373-376). Dr. Taylor concluded that

despite McClintock’s claims of migraine headaches, cataracts, hiatal hernia, tendonitis in the knee,

obesity, fatigue, anxiety and sleep problems, she was “able to participate in work related activities

almost fully.” (Tr. 376). 

On September 21, 1995, a Psychological Report was prepared by Francisco Sanchez,

Ph.D., at the request of DDS. (Tr. 377-380). McClintock’s presenting complaint was

anxiety. (Tr. 377). Dr. Sanchez did not find any substantial psychological impairments and

stated that:

[McClintock’s] functional capacities in terms of understanding,

adjusting, relating, and following directions are adequate. Her

ability to concentrate and attend to task is normal. Reasoning

and decision making was adequate. She is capable of doing

simple, non-skilled work.

(Tr. 380). 

 In June 1996, Ricci Silberman, P.A., reported that McClintock requested Silberman

to complete disability forms because “Social Security wants her to have disability . . . .” (Tr.

392). Silberman noted that McClintock was “attempting to get disability for cataract

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problem, severe migraines and [a] hiatal hernia.” (Tr. 392). McClintock was referred to a

neurologist and an ophthalmologist but Silberman indicated that she was “not comfortable

with doing a disability form it is not something I normally deal with and her diagnoses are

no reason for disability as a result of this.” (Tr. 392).

In October 1996, Jamie Monroe, M.D., found that McClintock was presbyopic, but

that her visual acuity was 20/30 bilaterally with correction, and that her visual field defects

were “not consistent with any specific neurological deficit or ocular disease.” (Tr. 407). 

Also in October 1996, McClintock was seen by Jeanette Wendt, M.D., a neurologist,

for her migraine headaches. (Tr. 405-406). The neurological findings were normal. Dr.

Wendt noted that McClintock was “somewhat reluctant” to take the prescribed daily

medication and noted that she also prescribed Tylenol 3 to take as needed. (Tr. 406). 

In November 1996, McClintock’s insomnia was evaluated by Ezequiel Esparza, M.D.

(Tr. 412-414). Her insomnia was described as “debilitating,” but did not meet the criteria for

diagnoses of depression, psychotic disorder, mood disorders, or anxiety disorders. (Tr. 413).

Dr. Esparza’s plan was to refer McClintock to a sleep disorder clinic, but did not prescribe

medication, noting that “[t]here seems to be some organic factors going on, specifically

related to caffeine and nicotine.” (Tr. 414).

Beginning in May 1997, Mary Ann Coady, M.D., from CODAC Behavioral Health

Services, began seeing McClintock. Dr. Coady wrote a note to DES indicating that she was

treating McClintock for insomnia and that she was “unable to work at this time” and should

be “re-evaluated in six months.” (Tr. 422). In December 1997, Dr. Coady again indicated

that McClintock was “unable to work,” but in January 1998 noted that she was being treated

with a new medication and “may need 6 months for treatment before she is able to work.”

(Tr. 421). In July 1998, Dr. Coady noted that McClintock “reports she is unable to work at

this time,” and will be “re-evaluated in 6 months.” (Tr. 419).

In May 2003, McClintock’s corrected visual acuity was again reported as 20/30 in

both eyes. (Tr. 436).

In June 2003, Stephen Cohen, M.D., McClintock’s primary care physician, noted that:

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I told her that I cannot keep writing letters in support of

disability for her, in the long run. I believe that her conditions

will be cured, or at least relived enough to work, by surgery and

treatment. She has not followed up with treatments as

prescribed by Dr. Baron, does not wear her eyeglasses despite

having complaint of poor vision that prevents her from working.

(Tr. 477 & 479).

In August 2003, McClintock saw Edward Schwager, M.D. (Tr. 476). Dr. Schwager

reported that this was her first office visit with him and that she was transferring from Dr.

Cohen because it was McClintock’s impression that “Dr. Cohen is insisting that she proceed

with surgery which she does not feel that she needs an [sic] order for him to continue her care

and deal with disability paperwork, etc.” (Tr. 476). Dr. Schwager found that, based on a

limited examination, he did not find her to be “severely disabled at this time.” (Id.). He also

noted that McClintock “stated that vocational rehab would not work with her because her

disabilities [were in] too many different areas of her body.” (Id.). 

In November 2003, ophthalmologist Kenneth S. Snow, D.O., in a letter to Dr.

Schwager, stated that he had followed McClintock “for some time with congenital cataracts,”

and noted that, “[a]pparently she was seen by another ophthalmologist, who recommended

cataract surgery.” (Tr. 533). Dr. Snow then reported that:

Certainly it may be possible that cataract surgery should be done

in the future, but today her visual acuity is 20/30, does not drop

in ambient light and really does not meet the criteria for cataract

surgery. [McClintock] is also doing well visually and does not

feel like she’s had a significant loss in her vision.

(Id.). Based on these observations, Dr. Snow indicated that the best approach would be to

observe McClintock and see her again in a year. (Id.). 

B. University of Arizona Vocational Assessment

In February, March and April of 2000, McClintock was referred to the Disability

Assessment Research Clinic for the stated purpose of “determining her capacity to participate

in a vocational rehabilitation program . . . .” (Tr. 587). She was seen by Anthony Bavry,

M.D., who noted her history of musculoskeletel problems, migraines, insomnia, and hiatal

hernia. (Tr. 585). He found that McClintock could lift 20 pounds occasionally and 10

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pounds frequently, walk/stand for less than 6 hours a day, and could not sit for 6 hours a day.

(Tr. 585). In describing her employment barriers, Dr. Bavry stated that:

Overall this patient’s motivation appears to be on getting on

disability. She first applied for disability 10 years ago and was

unsuccessful at this time, she reapplied in 1995 and has been

trying to get on disability since that time. From a medical

standpoint, there is little objective evidence of this patient being

profoundly disabled. She would most certainly benefit from

physical therapy, given her numerous and somewhat vague

musculoskeletal complaints.

(Tr. 586). 

As part of the vocational evaluation, McClintock was also seen by Charles Rastatter,

Ed.D., in March 2000. (Tr. 587-96). Although Dr. Rastatter found that McClintock “has a

number of excellent cognitive performance skills and abilities that would benefit her in a

work situation,” and that she would be “best served in a Sedentary or Light Work

situation,”he concluded that “because of her frequent episodes of migraine headaches, she

will probably be absent from work on a regular basis,” and due to this condition could have

“significant problems in finding and maintaining regular employment in any competitive

labor market job.” (Tr. 595). His recommendations were to obtain additional information

about her psychological and physical status so that her vocational outlook could be fully

determined. (Tr. 595-96).

On April 4, 2000, David Smith, D.Ed., interviewed McClintock and competed a final

report for McClintock’s vocational rehabilitation evaluation. (Tr. 612-16). Dr. Smith noted

that McClintock believes her most disabling condition is her visual problems, that she

“brought numerous medical files which attested to her migraine headache history, visual

problems and knee involvement,” and stated that she weighs “in excess of 200 lbs.” He

stated that he saw “no unusual psychological characteristics.” (Tr. 613). Dr. Smith indicated

that McClintock’s visual problems “appear to be somewhat debilitating as well as the

physical limitations which would certainly need to be addressed were the client to attempt

to work an eight hour day.” (Tr. 614). He concluded that, “until her visual problems are

resolved, she will be severely impaired,” and that “until her eye problems are resolved, her

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physical capacities, which are diminished, will prevent her from participating in any training

program designed to prepare her for sedentary work. (Tr. 615). Dr. Smith recommended that

McClintock be examined by an eye specialist to see if there was a relationship between her

vision and her headaches, that her depression treatment be assessed, and that “she may be a

candidate for SSDI while training for a sedentary position.” (Tr. 616).

C. Lay Witness Statement

In April 2004, McClintock’s sister, Carol Kubachi wrote a letter to McClintock’s

attorney. (Tr. 253-54). In the letter, Ms. Kubachi presented her recollection of

McClintock’s childhood and described her medical history. She stated that McClintock was

bright but had trouble in school due to her cataracts. (Tr. 253). Her vision problems also

caused headaches and, at age 9 or 10, started having migraine headaches. (Id.). She

described more recent migraine episodes, her history of hiatal hernia, low grade dysplasia,

a torn ligament in her right knee, two bulged disks in her lower back, and a minor tear in the

rotator cuff of her left shoulder. (Tr. 253). Ms. Kubachi also revealed that she and

McClintock cared for their mother who had recently suffered a stroke. (Id.). She stated that

it took both of them to tend to their mother because she was “a heavy woman.” (Tr. 254).

D. McClintock’s Testimony

McClintock testified that she worked for a dry cleaner and as a housekeeper in the

early 1990s, but that she had problems with those jobs due to her hernia and migraines. (Tr.

703-704). She stopped working altogether in July of 1992. (Tr. 704). 

Her typical migraine pattern was one or two migraines per week; they would last an

average of six hours. Sometimes, a couple of days. She described the migraines as causing

intense pain and rendering her unable to talk or feel parts of her body. (Tr. 704).

McClintock treated the migraines by going to a quiet dark place to wait it out. Even after the

migraine has ceased, she would experience residual pain for two or three days and have

trouble with her speech and word selection. (Tr. 705). Class 2 pain killers such as

Oxycontin did help the pain, but did not do anything for the auras, vision, nausea, and

numbness. (Tr. 706). 

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 McClintock also testified that she had trouble with her vision. After about 20 or 30

minutes of reading, she would get a tension headache from eye strain. (Tr. 706).

McClintock also described having insomnia. (Tr. 706). She could sleep about 90 minutes

at a time, and sometimes goes 20 hours without any sleep. (Tr. 707). She was treated with

multiple medications that did not resolve her problems. (Tr. 707-708). 

Additionally, McClintock testified that she has a torn rotator cuff that is non-surgical,

but causes her sharp pain. (Tr. 708). She also stated that she has a hiatal hernia and Barrett’s

esophagitis. She treats the esophagitis with Prilosec, but that leaves her nauseous. (Tr. 709).

She has problems with her left hip that are related to bulging discs and arthritis in he lumbar

spine. This condition renders her unable to bend, sit for very long, or walk more than 5 or

10 minutes. (Tr. 710).

III. ALJ's Decision

In the decision dated January 27, 2005, that ALJ found that McClintock had no history

of past relevant work and had never engaged in substantial gainful activity. (Tr. 23, 34). He

conlcuded that McClintock suffered from the following severe impairments: congenital

cataracts; hiatal hernia; GERD; insomnia; obesity; and migraine headaches. (Tr. 23, 34).

None of the listed impairments were found to meet or equal any of the impairments listed in

20 C.F.R. 404, subpart P, Appendix 1, and the ALJ proceeded to evaluate whether

McClintock had the RFC to adjust to other work. (Id.) He concluded that she had the RFC

to frequently lift/carry ten pounds and occasionally lift/carry 20 pounds, sit for about six

hours and stand/walk for about six hours in an eight hour work day, and that McClintock’s

visual deterioration prevented her from working around unprotected heights or dangerous

equipment. (Tr. 34-35). The ALJ found that she had no past relevant work. (Tr. 23, 35).

Relying on the Medical-Vocational Guidelines, 20 C.F.R. part 404, subpt. P, App. 2, the ALJ

determined that McClintock was not disabled because she could perform a significant

number of jobs existing in the national economy and therefore was not disabled under the

Social Security Act.. (Tr. 35-35). 

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IV. Discussion

Whether a claimant is disabled is determined using a five-step sequential evaluation

process. To establish disability, the claimant must show (1) she is not engaged in SGA, (2)

she has a severe physical or mental impairment, and (3) the impairment meets or equals a

listed impairment, or (4) her residual functional capacity precludes her from performing her

past work. At step five, the ALJ must show that the claimant has the residual functional

capacity to perform other work that exists in substantial numbers in the national economy.

20 C.F.R. § 416.920(a)(4)(i) - (iv). While the claimant has the burden of proof at steps one

through four, “the ALJ has an affirmative duty to assist the claimant in developing the record

at every step of the inquiry.” Bustamante v. Massanari, 262 F.3d 949, 954 (9th Cir. 2001).

A. Credibility Assessment

Determinations of a claimant's credibility are to be made by the Commissioner

through the ALJ. Talifson v. Secretary of HHS, 554 F.Supp. 575, 580 (D.Mont. 1982). A

reviewing court must give "great deference to credibility determinations made by

administrative law judges." Silver v. United States Postal Service, 951 F.2d 1033, 1042 (9th

Cir.1991). A finding that a claimant is less than credible must have some support in the

record. Talifson, 554 F.Supp. at 580. However, these findings must be sufficiently specific

to allow a reviewing court to conclude that the ALJ rejected the claimant’s testimony on

permissible grounds and did not arbitrarily discredit a claimant's testimony. Bunnell v.

Sullivan, 947 F.2d 341, 345-56 (9th Cir. 1991) (citation omitted). 

McClintock asserts that the ALJ misconstrued statements from her sister, Connie, and

improperly relied on them to support an adverse credibility finding. Specifically, Connie

provided a statement that indicated both she and McClintock were caring for their mother,

but McClintock contends that the ALJ incorrectly construed the letter as indicating that

McClintock was caring for her mother alone. Plaintiff’s Memorandum, pp. 3-4. Looking to

the decision, the only reference to the letter appears at page 9. (Tr. 30). There, the ALJ

states that Connie “has been out of work for three months and they both [she and

McClintock] must be there to physically care for their mother.” (Id.). Based on that

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statement, it appears the ALJ interpreted the letter just as McClintock contends he should

have.

Next, McClintock asserts that the ALJ failed to properly analyze her credibility

because he ignored evidence from the University of Arizona’s Disability Assessment that

demonstrates her motivation but recognizes the impairments that limit her ability to work.

Plaintiff’s Memorandum, pp. 5-6. McClintock notes that the Disability Assessment

concluded that she could not be competitively employed until her eye problems were

resolved. However, the ALJ’s decision to reject this opinion is supported by other evidence

in the record. As the Commissioner points out, Dr. Bavry, the only physician who evaluated

her at the University of Arizona, reported no visual limitations in summarizing her medical

condition. (Tr. 585). More important, however, the specialists who examined her found that

her vision was not disabling, but was actually 20/30 bilaterally with correction. (Tr. 407,

536, 581). Despite this evidence, McClintock complains that the ALJ failed to note “How

those opthalmological findings would indicate that McClintock was able to work.”

Plaintiff’s Memorandum, p. 6. Although the ALJ does not expressly state his conclusion, the

Court can think of no other than the fact that he concluded that McClintock’s vision was not

disabling. The record provides ample support for that conclusion.

B. McClintock’s Non-Compliance

McClintock objects to the ALJ’s reliance on her non-compliance with medical

treatment as support for his decision to discount the alleged intensity and duration of her pain

complaints. (Tr. 31). Social Security Ruling 96-7 outlines the criteria for evaluating a

claimant’s credibility and provides that claims of pain may be deemed less credible where

the “frequency of treatment is inconsistent with the level of complaints, or if the medical

reports or records show that the individual is not following the treatment as prescribed and

there are no good reasons for this failure.” Id. The Ruling further provides that:

the adjudicator must not draw any inferences about an

individual’s symptoms and their functional effects from a failure

to seek or pursue regular medical treatment without first

considering any explanations that the individual may provide, or

other information in the case record, that may explain infrequent

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1. The Secretary issues Social Security Rulings to clarify the Secretary’s regulations and policy.”

Bunnell v. Sullivan, 947 F.2d 341, 346 n. 3 (9th Cir. 1991). Although they do not have the force of

law, the rulings represent the Secretary’s interpretation of its regulations. Id. They are therefore

given deference by courts unless they are inconsistent with the statute or regulations. Id.

or irregular medical visits or failure to seek medical treatment.

Id. 

Here, the ALJ did not seek an explanation from McClintock regarding why she

declined certain treatments and did not comply with other treatment recommendations. In

her memorandum, she explains that she did try to take medications for her headaches and that

her doctors had not recommended surgery for her eyes. The ALJ’s failure to explore these

explanations was in violation of SSR 96-7p and merit the remand of this action on that point.

C. Residual Functional Capacity Assessment

The ALJ found that obesity, one of McClintock’s impairments, was considered

“severe” within the meaning of the Social Security Act. (Tr. 34). However, he did not

consider that condition in combination with her other identified ailments. The Commissioner

has issued a Ruling addressing the role of obesity in disability assessments.1

 Social Security

Ruling 02-1p (2002), 2000 WL 628049, provides that obesity can be a severe impairment if,

when considered alone or combined with other impairments, it causes more than a slight

limitation on a individual’s ability to perform basic work. Id. In assessing the severity of

obesity, the Ruling provides that an “individualized assessment of the impact of obesity on

an individual’s functioning” is necessary, and that, if obesity is found to be a medially

determinable impairment, “any functional limitations resulting from the obesity” must be

considered in the RFC assessment. Id.

In his Decision, the ALJ recognized that obesity was one of the impairments alleged

by McClintock that are considered to be “severe” under the Social Security Act. (Tr. 23).

However, other than that mention, obesity was not considered in the Decision. It is the ALJ’s

responsibility to determine the effect of a claimant’s obesity on her other impairments, as

well as its effect on her overall health and ability to work. See Celaya v. Halter, 332 F.3d

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1177, 1182 (9th Cir. 2003). By failing to discuss and consider McClintock’s obesity in the

disability analysis, the ALJ did not fulfill these requirements.

D. ALJ’s Reliance on the Medical-Vocational Guidelines

The Medical-Vocational Guidelines, commonly known as “the grids,” are a matrix

system for handling claims that involve substantially uniform level of impairment. See 20

C.F.R. pt. 404, subpt. P, app. 2. McClintock contends that the ALJ erred by relying on the

grids, rather than obtaining testimony from a Vocational Expert, because she is suffering

from a vision impairment that amounts to a significant non-exertional limitation. See Tackett

v. Apfel, 180 F.3d 1094, 1101- 1102 (9th Cir. 1999) (noting that “significant non-exertional

impairments, such as poor vision . . . may make reliance on the grids inappropriate.”)

However, as discussed above, the ALJ’s determination that McClintock’s functional abilities

are not significantly limited by her vision was supported by the record. As such, the ALJ was

not required to consult a VE in this regard. However, because the ALJ erred in not inquiring

into McClintock’s reasons for not following certain medical advice and not considering her

obesity, the ALJ will need to reconsider her RFC on remand and may reconsider the

necessity of consulting with a VE. 

V. Recommendation

The Magistrate Judge recommends that the District Court, after its independent review

of the record, enter an Order granting in part and denying in part Plaintiff's Motion for

Summary Judgment [Doc. No. 16], granting in part and denying in part Defendant's

Cross-Motion for Summary Judgment [Doc. No. 19], and remanding this action for further

consideration consistent with this Report and Recommendation.

This Recommendation is not an order that is immediately appealable to the Ninth

Circuit Court of Appeals. Any notice of appeal pursuant to Rule 4(a)(1), Federal Rules of

Appellate Procedure, should not be filed until entry of the District Court's judgment. 

However, the parties shall have ten (10) days from the date of service of a copy of this

recommendation within which to file specific written objections with the District Court. See

28 U.S.C. § 636(b)(1) and Rules 72(b), 6(a) and 6(e) of the Federal Rules of Civil Procedure.

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Thereafter, the parties have ten (10) days within which to file a response to the objections.

If any objections are filed, this action should be designated case number: CV 06-363-TUCJMR. Failure to timely file objections to any factual or legal determination of the Magistrate

Judge may be considered a waiver of a party's right to de novo consideration of the issues.

See United States v. Reyna-Tapia 328 F.3d 1114, 1121 (9th Cir. 2003) (en banc).

DATED this 25th day of April, 2008.

Case 4:06-cv-00363-JMR Document 34 Filed 04/25/08 Page 13 of 13