Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alsd-1_05-cv-00217/USCOURTS-alsd-1_05-cv-00217-0/pdf.json

Parties Involved:
Jo Anne B. Barnhart
Defendant
Samuel L. Johnson
Plaintiff

Document Text:

IN THE UNITED STATES DISTRICT COURT

FOR THE SOUTHERN DISTRICT OF ALABAMA

SOUTHERN DIVISION

SAMUEL L. JOHNSON, *

 *

Plaintiff, *

 *

vs. * Civil Action No. 05-00217-KD-B

 *

JO ANNE B. BARNHART, *

Commissioner of * 

Social Security, *

 *

Defendant. *

REPORT AND RECOMMENDATION

Plaintiff Samuel L. Johnson (“Plaintiff”) brings this action

seeking judicial review of the final decision of the Commissioner

of Social Security denying his claim for supplemental security

income under Title XVI of the Social Security Act (the “Act”), 42

U.S.C. § 1381 et seq. This action was referred to the undersigned

for report and recommendation pursuant to 28 U.S.C. § 636(b)(1)(B).

Oral argument was held on February 2, 2006. Upon consideration of

the administrative record and memoranda of the parties, it is

recommended that the decision of the Commissioner be REVERSED and

REMANDED. 

I. Procedural History

Plaintiff protectively filed an application for disability

benefits on September 28, 2000, alleging disability since February

1, 1998 due to a depressive disorder NOS, nerves, hypertension,

borderline intellectual functioning, and a back injury/low back

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Plaintiff previously filed an SSI application on June 29, 1994, which

was denied on June 27, 1996; he appealed that decision and his claim was

remanded on February 11, 1998 and denied on October 20, 1999. (Id. at 37-45).

2

Plaintiff filed additional SSI applications in October 2000 and April

2000. (Id. at 72-77).

2

pain. (Tr. 20, 49-50, 80, 89, 93, 181-182).1 Plaintiff’s

application was initially denied and upon his request for

reconsideration. (Id. at 57-61). Plaintiff then filed a request

for a hearing before an Administrative Law Judge (“ALJ”). (Id. at

62).2 On July 2, 2003, ALJ Stuart J. Wein (“ALJ Wein”) held an

administrative hearing which was attended by Plaintiff, his

representative and a vocational expert. (Id. at 178-209). On

October 16, 2003, ALJ Wein issued an unfavorable decision in which

he concluded that while Plaintiff has the severe impairment of

borderline intellectual functioning/mild mental retardation, his

impairment does not meet or medically equal one in the Listings.

(Id. at 17-27). ALJ Wein determined that Plaintiff retains the

residual functional capacity (“RFC”) for routine repetitive tasks

at all exertional levels and, utilizing the testimony of a

vocational expert, also concluded that he can perform other work

existing in significant numbers in the national economy; thus, he

is not disabled. (Id.) Plaintiff sought review of the ALJ’s

decision, and on March 10, 2005, the AC denied his request for

review; thus, the ALJ’s decision became final. (Tr. 4-6, 11-12).

The parties agree that this case is now ripe for judicial review

and is properly before this Court pursuant to 42 U.S.C. §§ 405(g)

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and 1383(c)(3).

II. Background Facts

Plaintiff was born on July 21, 1959, and was 43 years old at

the time of the administrative hearing. (Tr. 22, 72, 186-187). He

attended special education classes and completed the 12th grade.

(Id. at 187). Plaintiff does not have any past relevant work

(“PRW”). (Id. at 26, 187). At the July 2, 2003 hearing, Plaintiff

testified that his back problems made it difficult for him to do

any lifting. (Id. at 191, 193-196). According to Plaintiff, 50

pounds is the heaviest weight he has lifted in the past year. (Id.

at 191). Plaintiff also testified that he has problems with his

left elbow. (Id. at 192-194). Plaintiff testified that he injured

his elbow 4-5 years ago in a fight, that he sought medical

treatment at USA hospital and Stanton Road Clinic for same, and

that his elbow was placed in a cast for a month. (Tr. 192-194).

According to Plaintiff, his elbow causes aches/pains and affects

his ability to lift with his left hand. (Id. at 193-194).

Plaintiff testified that his left hand is his dominant hand, that

he can lift 50 pounds on his right side, but that he is limited to

5-10 pounds with his left side. (Id. at 191, 193-194). Plaintiff

also testified that he does not think he can perform light jobs

(laundry work, production, assembly type work - where he would not

have to lift more than 20 pounds). (Id. at 195-196). According to

Plaintiff, he spends his time sitting at home watching television,

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This Court’s review of the Commissioner’s application of legal

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

4

or his niece picks him up to go to her house to sit, watch

television and talk. (Id. at 197-198). As for household chores,

Plaintiff reported that his stepmother pays his bills and does his

grocery shopping. (Id. at 198-199). Plaintiff also testified that

he has no hobbies, and does not exercise, perform any outside

chores, household repairs or yard work. (Tr. 198-199, 201).

III. Issues on Appeal

A. Whether the ALJ erred by failing to find that Plaintiff has a

mental and physical impairment imposing an additional and

significant work-related limitation of function to meet or

medically equal Listing 12.05C, and in so doing, failed to

state the weight he assigned to the opinions of State Agency

physicians Drs. Shaikh and Eno, in violation of SSR 96-6p?

B. Whether the ALJ erred by failing to evaluate Plaintiff’s

mental impairment as required by Section 416.920a?

IV. Analysis

A. Standard of Review

In reviewing claims brought under the Act, this Court’s role

is a limited one. This Court’s review is limited to determining 1)

whether the decision of the Secretary is supported by substantial

evidence, and 2) whether the correct legal standards were applied.

Martin v. Sullivan, 894 F.2d 1520, 1529 (11th Cir. 1990).3 A court

may not decide the facts anew, reweigh the evidence, or substitute

its judgment for that of the Commissioner. Sewell v. Bowen, 792

F.2d 1065, 1067 (11th Cir. 1986). The Commissioner’s findings of

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fact must be affirmed if they are based upon substantial evidence.

Brown v. Sullivan, 921 F.2d 1233, 1235 (11th Cir. 1991); Bloodsworth

v. Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983) (finding that

substantial evidence is defined as “more than a scintilla but less

than a preponderance,” and consists of “such relevant evidence as

a reasonable person would accept as adequate to support a

conclusion[]”). In determining whether substantial evidence

exists, a court must view the record as a whole, taking into

account evidence favorable, as well as unfavorable, to the

Commissioner’s decision. Chester v. Bowen, 792 F.2d 129, 131 (11th

Cir. 1986); Short v. Apfel, 1999 U.S. DIST. LEXIS 10163 (S.D. Ala.

1999).

B. Discussion

An individual who applies for Social Security disability

benefits must prove her disability. 20 C.F.R. §§ 404.1512,

416.912. Disability is defined as the “inability to do 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 twelve months.” 42 U.S.C. §

423(d)(1)(A); 20 C.F.R. §§ 404.1505(a), 416.905(a). The Social

Security regulations provide a five-step sequential evaluation

process for determining if a claimant has proven her disability.

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The claimant must first prove that he or she has not engaged in

substantial gainful activity. The second step requires the claimant to prove

that he or she has a severe impairment or combination of impairments. If, at

the third step, the claimant proves that the impairment or combination of

impairments meets or equals a listed impairment, then the claimant is

automatically found disabled regardless of age, education, or work experience. 

If the claimant cannot prevail at the third step, he or she must proceed to

the fourth step where the claimant must prove inability to perform their past

relevant work. Jones v. Bowen, 810 F.2d 1001, 1005 (11th Cir. 1986). In

evaluating whether the claimant has met this burden, the examiner must

consider the following four factors: (1) objective medical facts and clinical

findings; (2) diagnoses of examining physicians; (3) evidence of pain; (4) the

claimant’s age, education and work history. Id. at 1005. Once a claimant

meets this burden, it becomes the Commissioner’s burden to prove at the fifth

step that the claimant is capable of engaging in another kind of substantial

gainful employment which exists in significant numbers in the national

economy, given the claimant’s residual functional capacity, age, education,

and work history. Sryock v. Heckler, 764 F.2d 834 (11th Cir. 1985). If the

Commissioner can demonstrate that there are such jobs the claimant can

perform, the claimant must prove inability to perform those jobs in order to

be found disabled. Jones v. Apfel, 190 F.3d 1224, 1228 (11th Cir. 1999). See

also Hale v. Bowen, 831 F.2d 1007, 1011 (11th Cir. 1987) (citing Francis v.

Heckler, 749 F.2d 1562, 1564 (11th Cir. 1985)).

5

While there are additional records in the file relating to other

treatment Plaintiff has received, they are irrelevant for purposes of this

appeal, and as such, merit no further discussion here.

6

20 C.F.R. §§ 404.1520, 416.920.4 See, e.g., Crayton v. Callahan,

120 F.3d 1217, 1219 (11th Cir. 1997). 

In the case sub judice, the ALJ concluded that Plaintiff has

the severe mental impairment of borderline intellectual

functioning/mild mental retardation but does not meet/equal a

Listings impairment, such that he is not disabled within the

meaning of the Act. See supra. The undersigned’s review of the

relevant5 evidence of record reveals that Plaintiff was treated

from May 26, 1998-February 10, 2000 at the Mobile Mental Health

Center (“MMHC”). (Tr. 128-135). He complained of back pain, but

denied any hallucinations or hearing voices. (Id.) He had an

appropriate affect and appearance, and was given medication. (Id.)

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On April 9, 2001, Plaintiff was examined by consultative

examining physician Ilyas Shaikh, M.D. (“Dr. Shaikh”), at the

request of the State Agency. (Id. at 138-142). Dr. Shaikh’s

examination of Plaintiff revealed: normal bilateral symmetrical

motor strength of the upper/lower extremities to abduction,

adduction, flexion and extension; normal fine motor skills; no

rigidity/spasticity; grip strength of 5/5 and bilaterally

symmetrical, intact sensations; a mal-healed old dislocation of the

left elbow with decreased extension of the left arm (left arm was

semi-flexed and he was unable to extend beyond 30 degrees); range

of motion deficit at his left elbow (unable to fully extend and

flexion was about 130); supination and pronation of left

elbow/forearm was noted as compromised; he had a mild range of

motion deficit; only near normal flexion of the left elbow; normal

extension/rotation of the dorsolumbar spine; and only near normal

flexion of the dorsolumbar spine. (Id.) Dr. Shaikh’s impression

was that Plaintiff had a left arm range of motion deficit due to

mal-union of elbow, a history of low back pain, a history of low to

average intellegence, and a history of atypical psychosis. (Id.)

Dr. Shaikh opined that “Mr. Johnson has been throughly examined in

the past for mental retardation. He has also been treated for his

Lumbo-sacral strain. He has permanent disability to use his left

arm.” (Tr. 140).

On April 10, 2001, Jake Epker, Ph.D. (“Dr. Epker”) conducted

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In his decision, the ALJ mistakenly references the date of this

examination as September 28, 2000. (Id. at 23).

8

a comprehensive psychological evaluation of Plaintiff, finding as

follows (Id. at 143-145):

• his exam revealed no psychomotor agitation or

retardation, he was alert/oriented, he had normal

speech, he had goal directed thought processes, and

his intelligence was in the extremely low to

borderline range;

• he was diagnosed with a depressive disorder and

borderline intellectual functioning; and

• it was found that he was able to perform most

activities of daily living independently, he has

been inconsistent with following treatment

recommendations for his mood, he has had

questionable diagnoses with regard to his

hallucination reports, his report of variable

shifts in mood and depressive symptoms suggest he

was not experiencing a major depressive disorder

and his history of brief terms of employment were

not typically due to mental/physical problems.

Dr. Epker opined that Plaintiff could benefit from psychiatric

treatment/counseling, and if compliant, would likely experience an

improvement of his mood in the next 6-12 months, but that

regardless, his mood does not significantly interfere with his

ability to maintain independence in his activities of daily living.

(Id. at 145).

On May 16, 2001,6

 State Agency psychological consultant Ellen

Eno, Ph.D. (“Dr. Eno”) reviewed Plaintiff’s records and completed

a Psychological Review Technique form and Mental Residual

Functional Capacity assessment, noting as follows (Id. at 146-163):

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• regarding organic mental and affective disorders,

he has borderline intellectual functioning and a

depressive disorder nos;

• his mental impairments cause only a mild degree of

limitation with regard to his ADLs and maintaining

social functioning;

• he has a moderate degree of limitation in

maintaining concentration, persistence or pace;

• he has no repeated episodes of decompensation;

• he was moderately limited in his abilities to

understand/remember/carry out detailed

instructions, interact appropriately with the

general public, respond appropriately to changes in

the work setting and set realistic goals or make

plans independently of others; and

• he was not significantly limited in any other

abilities.

Dr. Eno opined that Plaintiff should be able to

remember/understand/carry out short, simple instructions and

attend/concentrate for 2 hour intervals, but should have minimal

interaction with the general public, infrequent changes in the work

setting, and may need help setting realistic goals. (Id. at 162).

1. Whether the ALJ erred by failing to find that Plaintiff

has a physical and mental impairment imposing an

additional and significant work-related limitation of

function to meet or medically equal Listing 12.05C, and

in so doing, failed to state the weight he assigned to

the opinions of State Agency physicians Drs. Shaikh and

Eno, in violation of SSR 96-6p?

Plaintiff claims that the ALJ erred in finding that he did not

meet Listing 12.05C because he failed to determine whether the malunion of his left elbow and/or his depression constitute a physical

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The ALJ noted in his decision that the records revealed that

Plaintiff’s full scale IQ was between 62 and 71 and that Dr. Epker described

his IQ as 62.89 for borderline intellectual functioning. (Id. at 24-25). 

Likewise, at the administrative hearing, Plaintiff’ IQ was identified as a

verbal 76, performance 67 and full scale 69, which would place him in the

borderline to MMR range. (Id. at 203-204). Thus, Plaintiff’s IQ - and the

first prong of Listing 12.05C - is essentially a non-issue here. 

8

See also e.g., Cobb v. Barnhart, 296 F. Supp. 2d 1295 (N.D. Ala. 2003);

Davis v. Shalala, 985 F.2d 531 (11th Cir. 1993)(quoting Listing 12.05C).

10

and/or mental impairment imposing an additional and significant

work-related limitation of function. Plaintiff adds that in so

doing, the ALJ failed to assign controlling weight to the opinions

of State Agency physicians Drs. Shaikh and Eno. As such,

Plaintiff’s appeal turns on the second prong7

 of Listing 12.05C:

whether Plaintiff has a physical and/or mental impairment imposing

an additional and significant work-related limitation of function.

See, e.g., Berryman v. Massanari, 170 Fed. Supp. 2d 1180, 1185-1187

(N.D. Ala. 2001). 

Listing 12.05C falls under § 12.00 MENTAL DISORDERS and

provides that:

Mental retardation refers to significantly subaverage

general intellectual functioning with deficits in

adaptive functioning initially manifested during the

developmental period; i.e., the evidence demonstrates or

supports onset of the impairment before age 22. The

required level of severity for this disorder is met when

the requirements in A, B, C, or D are satisfied ···· C.

A valid verbal, performance, or full scale IQ of 60

through 70 and a physical or other mental impairment

imposing an additional and significant work-related

limitation of function. 

20 C.F.R. Pt. 404, Subpt. P, App. 1, § 12.05 (emphasis added).8

 A

claimant meets the criteria for presumptive disability under

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See also e.g., Wilkinson on behalf of Wilkinson v. Bowen, 847 F.2d 660,

662 (11th Cir. 1987); Barron v. Sullivan, 924 F.2d 227, 229 (11th Cir. 1991);

Lowery v. Sullivan, 979 F.2d 835, 837 (11th Cir. 1992); Berryman v. Massanari,

170 F. Supp. 2d 1180, 1186-1187 (N.D. Ala. 2001); Cobb v. Barnhart, 296 F.

Supp. 1295, 1296-1297 (N.D. Ala. 2003). 

11

Listing 12.05C when the claimant presents a valid IQ score of 60-

70, an onset of impairment before age 22 and evidence of an

additional and significant mental or physical impairment (i.e.,

having more than “minimal effect” on the claimant’s ability to

perform basic work activities). See, e.g., Edwards by Edwards v.

Heckler, 755 F.2d 1513, 1516 (11th Cir. 1985).9 Claimant bears this

burden. Id. 

Based upon a review of the record, the undersigned finds that

substantial evidence does not support the ALJ’s determination that

Plaintiff does not fulfill the second prong of 12.05C, which

requires having “a physical or other mental impairment imposing

additional and significant work-related limitation of function.”

With respect to Plaintiff’s left elbow, the ALJ stated as follows

(Tr. 24):

Ilyas A. Shaikh, M.D., a neurologist, examined the claimant on

April 9, 2001. His impressions were that the claimant had a

left arm deficit due to mal-union of the elbow, a history of

low back pain, and a history of low average intelligence, and

a history of atypical psychosis . . . . 

Additionally, the ALJ also found as follows: 

. . . . there is inadequate evidence that the claimant

possesses a physical or other mental impairment that

imposes an additional and significant work-related

limitation of function, as required by Section 12.05 . .

. . At the hearing, the claimant testified that he had

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broken his elbow four or five years earlier, and that his

arm is crooked and affects his ability to lift. However,

in July of 2000, the claimant stepped on a nail while

helping his friend paint . . . and in April of 2002 he

strained his back while doing heavy lifting . . . . Both

incidents indicate that the claimant has not been limited

by the condition of his elbow. Additionally, claimant

has not received any treatment for his elbow during the

pertinent period . . . .

(Id. at 24-25 (emphasis added)). Clearly, the ALJ’s decision omits

the fact that during the administrative hearing, Plaintiff

testified that while he has the ability to lift on his right side,

his ability to lift on his left side is limited to only five to ten

pounds. See supra. Additionally, the ALJ’s decision makes no

mention of Dr. Shaikh’s finding that Plaintiff has a range of

motion deficit at his left elbow in that he is limited in his

ability to extend his elbow, and that he has a permanent disability

to use of his left arm. Id. Moreover, the ALJ failed to indicate

what weight, if any, he accorded Dr. Shaikh’s finding. SSR 96-6p;

20 C.F.R. §§ 404.1527(f)(2)(i)-(iii). 

Under SSR 96-6p, the opinions of State Agency physicians must

be treated by the ALJ as expert opinion evidence which can not be

ignored:

State agency medical . . . consultants are highly

qualified physicians . . . who are experts in the

evaluation of the medical issues in disability claims

under the Act. As members of the teams that make

determinations of disability at the initial and

reconsideration levels of the administrative review

process (except in disability hearings), they consider

the medical evidence in disability cases and make

findings of fact on the medical issues, including, but

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not limited to, the existence and severity of an

individual's impairment(s), the existence and severity of

an individual's symptoms, whether the individual's

impairment(s) meets or is equivalent in severity to the

requirements for any impairment listed in 20 C.F.R. part

404, subpart P, appendix 1 (the Listing of Impairments),

and the individual's residual functional capacity (RFC).

Because State agency medical . . . consultants and other

program physicians . . . are experts in the Social

Security disability programs, the rules in 20 C.F.R. [§§]

404.1527(f) and 416.927(f) require administrative law

judges and the Appeals Council to consider their findings

of fact about the nature and severity of an individual's

impairment(s) as opinions of nonexamining physicians . .

. . Administrative law judges and the Appeals Council are

not bound by findings made by State agency or other

program physicians and psychologists, but they may not

ignore these [State Agency] opinions and must explain the

weight given to the opinions in their decisions.

SSR 96-6p (emphasis added). See, e.g., McCloud v. Barnhart, 166

Fed. Appx 410 (11th Cir. 2006) (unpublished) (holding, in part, that

the case was due to be remanded both because the ALJ neither

explained the weight he gave to the report of claimant’s consulting

physician nor why he discredited same regarding her ability to

work, and because the ALJ ran afoul of the law when he failed to

explain the weight he gave to the state agency physician’s

opinions, because the law requires that he consider such opinions

and explain the weight assigned to same when he does not give

controlling weight to a treating source). Contrary to SSR 96-6p,

here, the ALJ omitted any mention of Dr. Shaikh’s finding that

Plaintiff has a permanent disability to the use of his left arm.

To the extent the ALJ rejected this aspect of Dr. Shaikh’s

evaluation, he is required to explain his reasons for doing so.

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This is particularly true where the ALJ has in essence rejected the

only medical evidence in the record regarding Plaintiff’s elbow

injury. Accordingly, this case should be remanded. Upon remand,

the ALJ shall expressly address what weight, if any, he accords Dr.

Shaikh’s findings regarding Plaintiff’s left elbow. The ALJ may

chose to re-contact Dr. Shaikh to solicit additional information

regarding specific functional limitations resulting from

Plaintiff’s left arm deficit.

IV. Conclusion

For the reasons set forth, and upon consideration of the

administrative record and memoranda of the parties, it is

recommended that the decision of the Commissioner of Social

Security, denying Plaintiff’s claim for supplemental security

income, is due to be REVERSED and REMANDED.

The attached sheet contains important information regarding

objections to this report and recommendation.

DONE this the 29th day of August, 2006.

 /s/ Sonja F. Bivins 

UNITED STATES MAGISTRATE JUDGE

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MAGISTRATE JUDGE’S EXPLANATION OF PROCEDURAL RIGHTS

AND RESPONSIBILITIES FOLLOWING RECOMMENDATION

AND FINDINGS CONCERNING NEED FOR TRANSCRIPT

1. Objection. Any party who objects to this recommendation or anything

in it must, within ten days of the date of service of this document, file

specific written objections with the clerk of court. Failure to do so

will bar a de novo determination by the district judge of anything in the

recommendation and will bar an attack, on appeal, of the factual findings

of the magistrate judge. See 28 U.S.C. § 636(b)(1)(c); Lewis v. Smith,

855 F.2d 736, 738 (11th Cir. 1988). The procedure for challenging the

findings and recommendations of the magistrate judge is set out in more

detail in SD ALA LR 72.4 (June 1, 1997), which provides, in part, that:

A party may object to a recommendation entered by a magistrate

judge in a dispositive matter, that is, a matter excepted by

28 U.S.C. § 636(b)(1)(A), by filing a “Statement of Objection

to Magistrate Judge’s Recommendation” within ten days after

being served with a copy of the recommendation, unless a

different time is established by order. The statement of

objection shall specify those portions of the recommendation

to which objection is made and the basis for the objection.

The objecting party shall submit to the district judge, at the

time of filing the objection, a brief setting forth the

party’s arguments that the magistrate judge’s recommendation

should be reviewed de novo and a different disposition made.

It is insufficient to submit only a copy of the original brief

submitted to the magistrate judge, although a copy of the

original brief may be submitted or referred to and

incorporated into the brief in support of the objection.

Failure to submit a brief in support of the objection may be

deemed an abandonment of the objection.

A magistrate judge’s recommendation cannot be appealed to a Court

of Appeals; only the district judge’s order or judgment can be appealed.

2. Opposing party’s response to the objection. Any opposing party may

submit a brief opposing the objection within ten (10) days of being

served with a copy of the statement of objection. Fed. R. Civ. P. 72;

SD ALA LR 72.4(b). 

3. Transcript (applicable where proceedings tape recorded). Pursuant

to 28 U.S.C. § 1915 and Fed.R.Civ.P. 72(b), the magistrate judge finds

that the tapes and original records in this action are adequate for

purposes of review. Any party planning to object to this recommendation,

but unable to pay the fee for a transcript, is advised that a judicial

determination that transcription is necessary is required before the

United States will pay the cost of the transcript.

/s/SONJA F. BIVINS 

UNITED STATES MAGISTRATE JUDGE

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