Exhibit

2:14-cv-11700-PDB-MJH Doc # 1-9 Filed 04/29/14 Pg 1 of 13 Pg ID 131
DiA$UTY C.CW1CMt

J3AE EW LNWRY

sow As soiae hcusework may jnyoiflbending lifting twisting and prelonged $4t4qiaád v4ouurning rnakiug beds wat4P floon sins bathtubá awl toflt

pittb.gl3pebJeet on thefloor caardng g4ó or groceries

i__Cp6j 8flflQ%flJ3 Whkh may involve bàding li%nm

twistiltB afltpro1onged standing re4u.ired bybathingthe patient dressing the patient and lifting

objects

CAjtGFCPATIENTS CHILDILFN Which may involve bending lifting and

o1tagl Standing as required by changi çhildren icthes bathing children cooking for the

w$ching the childn feeding tk iüken .c1ning and straightening up after the children

have exidned aatr treated the above name psieut4or injury sustained in the afoxernendoned

ooident Mapeuj otheiiij.wi have disabied theperson ftomthose activities that are ma4wd

3fl

ay.tiea.thapthe patfàt is dieebl$ froswQrk other from z440

Tepatimt iabiet reazxt to ertpIoymezatjt isthne btkt irticted front reegular wor-kdus

ornthe4te of aceltnt until --

The restitictietss include

Lifting objects that weigh more than jDouDdL

Eçssiye ben4ing

Proknged stading

Other ______

SNCUZ OF PHYSICIAN

f.jCN$ NAM

2:14-cv-11700-PDB-MJH Doc # 1-9 Filed 04/29/14 Pg 2 of 13 Pg ID 132
1/22/2OOQ 1311 FAX 12483541114 FAX 00 1/001

DISABILITY CthTtFXCATL

ItiIkAJoYt

Ihaveezinjne4 an4/çr freatdd theaba uarflepa$iàqt thjuty su3tainedii the atorthettjonod

abcidevt crAe aresuit of.the 1XIJUdGI GUSb1S4 Jersou fromrnoso actitjjts that gz matked

.L JflY ooivt1gt thpatieèWthsab1od from work ioterfrpnihós/c4

Tfi patient is abI to xetu toeih4cyment at.this -tim bu2 Is rethictedfrona mgtüj wQrk duties

U1 heiMe ofacofdejthgi1 .___ The rsstttiona ixc1ude

X4tngobjecsthatighrncretEaA rtda

Bceessive baa4thj

.Exceéive twisting

Piofonged standing

EOUSEWO1C bouat4vQrkxruI Ltivc beudiug lifting tWi3ti11g sad prolonged

4iug as required byncutnxting rnakthg.bedswsshing floorsSb bathtqbs and thiletE moving

fumithre1pitngup objecfs tht fIpoaptfi gërbqe ox groowzieu

CSRINGIORxgJj ATIENDS P$RSONAL tE5 V1zkthjnay iwo1ve bending lifting

twiatw end pronged atiudig as requiredty bathinj the patient dressing the patient end lifting

objects

dARING IFOR TUE PATrENflcXLDREN \Thich may invàlve bending lifting and

poionged stu.nding as required by chdflM1thildflflS clothes b%thing ohildren cooldng for the

children wath1aäg the chulen

feedite

OIIIIdDCn çleaningaad straightening up after the children

4/ bRtvnw

SXGNATVRE OFPli

PATIENT NAMz

1PriA kLkcci/ JIcrsr

4I

PBYSiflrVs NtE

2:14-cv-11700-PDB-MJH Doc # 1-9 Filed 04/29/14 Pg 3 of 13 Pg ID 133
Disability Certificate

have examined and/ or treated the above mentioned patient fo juries sustained in the

aforementioned accident As resWt ofthe injuries have disabled this patient from those

activities marked with check mark

-- -\ fl It is my opinion that the patient is disabled from world other fron4j4 to _/j_

The patient is able to return to hislher employment at this time with restrictions from

regular work duties from the date ofthe accident until _/_/ The restrictions include

Lifting objects that weigh more than pounds

Excessive bending

Excessive twisting

Prolonged standing

Other________

/I-Jousework As some housework may involve bending lifting twisting and prolonged

standing as required by vacuuming making beds washing floors sinks bathtubs and

toilets moving furniture picking up objects on the floor carrying groceries or garbage

Attending Care bathing toileting Bladder and bowel requirements bed pan routines

movement to and from the bathroom transferring from bed chair or other structure and

moving about indoors and outdoors moving turning and positioning the body while in

bed or in wheelchair eating and preparing meals dressing and changing clothes and

taking medications or other remedies that are ordinarily self administered

Caring for patients children which may involve bending lifting and prolonged standing

as required by changing childrens clothes bathing children cooking for the children

watching the children feeding the children cleaning up after the children

Driving

Physician Name fl2

Physician

Signatur1U

2:14-cv-11700-PDB-MJH Doc # 1-9 Filed 04/29/14 Pg 4 of 13 Pg ID 134
DISABILITY CERTIFICATE

have ex-arnineddIoi eatod the above nazxe patienttor IDJUO sustained in theaforementioned

ascident As resuM of the tajunes have disabled theersca from those activities that ar-c marked

withan

1- It-is epiai9n th tie patient isdisabledfroWwork other from to

__________

The patient is aWe to return tc employment .t tS time b$ is restriciecl from regul work duties

from the date of accident itjj The restrictions mclude

Lifting objects that weigh rnce than ___ poundL

$-xàsse bending

Excessive twisting

Prolonged standing

Other ______

-4-

s$Sixag

OuEWoRc anby acuwnttg

As .soine housework

making beds

may

wwshafloors1

izvvbfl1emdig

SflICS-J

li-ft

batitibs

twöfrg

and

and

toilets

flQ

raswng f%4ftWitr-e Pkig.-up 0jeOt$ on the floor carrying -.or-grocerLes

aCkRENC FOR THE PATIENTS PERSONAL t4FEEDS Which may involve bending lifting

t-isting andproiogj standing a-s required bybathing the patient dressing the patient and Lifting

OL$cts

L_ CARmiç FOR THE PkTLENTS CHILDREN Which rosy invoke bending liftintw4

.prpottged.staa4jg asrequiredby changing childr-ens Ihes bathing clijLdren CQOki4tg

Cl3reii watching the chiLdren feeding the children1 cleing- and straghtening up after the children

SJGNATjp OF PHySICIAN ATE ___________

DIAGNOSIS

DATE OF INJURY

FHYSICJAN3 NAME

2:14-cv-11700-PDB-MJH Doc # 1-9 Filed 04/29/14 Pg 5 of 13 Pg ID 135
O108/2001 1213 FAX 1248354114 FAXMEDICALE VALUATIONS fjOQ1iooi

DXSAJ3ILITY cERT1FWAT

FANT NAME DATE OP INJURy

DIAGNOSIS

hat LsLamned and/or treattd the aboV6 name pa fat injury ustauuui the

aCCjjeffl As rcujt ofthc ITIJL1IiCS

bavc thsabied the person fran those acnvsties that are msthed

witflnX

It is my pthion that thn patient isdisabMd from work other omtZt1k to

The paat IS able to return tO aifl iSts time but is restn from regular work duties

frorntbe datcofac1d5 untit The resthctiODS jthtde

.- Liftmgobjects that weigh more than pounds

5xcessVe bending

Excessive twisting

Prolonged stndirtg

OUter ________

JI1DUSEWoc Aa somemainvoive bending I3ft trnstrng and prainnged

$tandirg as requIad by vacuuming rnking beds washing floors 5ISI bcitUbs and totet moving

fumttrc Pickirg up objects on the floor cafrying garbage or groceries

ZARING FOR THE ATIENT$ PERSONAL NEEDS Whth may nvove bending itiing

tWu9Lina and PtOlongcd 5tanding required by bathing thc paiciu dressing the pahetit and Lifting

objects

......./kARIt4r Fop THE PATIENTS cFnfpctJLrfr1sc nay involve bending liftisig aavl

PIdIOI as seqtiiad by clunguig chjllrco4clEIhCS bIhiii cIuidittri cooking lot tI

hidrs U/atching ibe chtIdrej fcedisig he ehIrk4 r.iiuri an ti acghtening up Itci 11tL clifrt pu

..J3Q1V1Nc

st CU ItIYIcItj Ii

2:14-cv-11700-PDB-MJH Doc # 1-9 Filed 04/29/14 Pg 6 of 13 Pg ID 136
DiSABILITY CERTJFJCATE

PA DATE OF INJ1Y Jfl 07

DIAGNOSIS tr cj AJvtc Ree2tve4y

ban examined and/or treated the above name patient for injury sustained in the aforementioned

accident As result ofthe injufies have disabled the person fromthose activities that are marked

ither aJ

.s It is my opinion that the patient is disabled from work other from to La

The patient is able to return to employment at this time but is restricted from regular work duties

from the date ofaccident until ______ The restrictions include

Lifting objects that weigh more than pounds

Excessive bending

Excessive twisting

Prolonged standing

Other_______

HOUSEWORK As some housework may involve bending lifting twisting and prolonged

standing as required by vacuuming making beds washing floors sinks bathtubs and toilets moving

furniture picking up objects on the floor carrying garbage or groceries

CARING FOR THE PATIENTS PERSONAL NEEDS Which may involve bending lifting

twisting and prolonged standing as required by bathing the patient dressing the patient and lifting

objects

CARING FOR THE PATIENTS CHILDREN Which may involve bending lifting and

prolonged standing as required by changing childrens clothes bathing children cooking for the

children watching the children feedingihechildren cleaning and straightening.up after the children

DRIVING

SIGNATURE OF PHYSICIANC DATE ________

PHYSICIANS NAME

2:14-cv-11700-PDB-MJH Doc # 1-9 Filed 04/29/14 Pg 7 of 13 Pg ID 137
fflSABILEIY CERTJIFWATE

PAT NAME ___________________________ tLTii OF LNJURY __________ ___________

DLAGNOSIS tJkVjJ\ 4-O4i5-J-.--

have exarnned 3JldJOT treated the above name patient for injury sustained in the aforementioned

accident As result ofthe injuries1 bve disabled the person from those activities that are marked

with an

it 2ff.1iY

The patient is aheEo return to employment at this time but restrktd from regular work duties

from the date of accident until ________ The restrictions include

____ Lifting objects that weigh more nan pounds

Excessive bending

Excessive twistin

Prolonged standing

Other ____________I

fOUSEWOPS As some housework may invohe bending Ithing twisting and proJoned

standing as required by vacuuming making beds washing floors sinks bathtubs and toilets moving

ftirnituTe picking up objects on the floor cañying garbage or groceries

CAEUNG FOR THE PATENTS PERSONAL NEEELS \Vhich i-nay involve bending lifting

twisting and prolonged standing as required by bathing the patient dressing the patient and lifting

objects

CARING FOR TIE PATENFS CE-HLDREN Which may involve bendhtg lifting arid

prolonged standing as required by changing childrens clothes bathing children cocking for the

children watching the children feeding the children1 cleaning and traightening up after the children

RIYiNG

SiQYATVRE OF ph5sC.tN ___________

FEYSJCILNS NAME

DATE 4/u/u

.n .n .ni

2:14-cv-11700-PDB-MJH Doc # 1-9 Filed 04/29/14 Pg 8 of 13 Pg ID 138
Sutpws arp uipjq $upoj q1 4uJp fiutueje pu 2uu2q21uaj dn taije 941 pIq

Xq 8UUV3 $4UipL4o tnqiop SUtpeq uvç4qo Eupjooa ELi pa5uojod 2upueiz si paatiihi

DMDIY ilIJJOd S1IN2IXYd N2fl1Q1IH3 4qM A%flu CAIDAR 2upuaq SU1JJJ UB

sp3fqo

iued utssp Wjd pu 2UE1JrL paqnbi As 2uqvq otn 2uqjm pus pri2uojoid ffupavfl

io $CINSISYd 1fliOSlid tpq joqpn t$upJ1

1mLLiTg txprd dii sfqo tb JQDjJ thIX.LN3 2aqs ao 9poi2

aUçpUS 91 ptqnnz Sct UJW1U13tA BUflUtU spaq uqs/E% tgioQll 1Ui9 tsqnqitq fU S1flo1 2iiaow

NB0M3SR00 SV uJós j1oMasno4 XW GAtOMI uw 42ujq iupyM pu p2iiojoid

iqi

$UOjOI

kjn svnfqo t2IAN41 QIQtU sptind

mutt oqi suoII3pMi PPr WO-U Q3 1uwoBJo

ci wauiLojdw ii towq nq St jGU4SD4 LLiQIJ 1BIU5U S1$P uq8d OI4 Wfl131

Qi _-4LuaLu ii Ausç uo3utda wii uii .liafltd ptctB3Jp WOJJ %JGM 4Y

x1

IUppD8 lrctsn sapnftq aq p1p 411 uoud WQ1J QU $1A1$ 4Zfl9 3iPtU

SO/PUS A0q2 suinu 1uo1Bd aoj X.rnfu paujnsns qi puo9ttuieiap flq

VIII ISONO

aLYcI Ac tAirnrsfl IHaJLVJ YN

AIFITRYSIG UV3UI1UED

o3B3O RECEIVE

osZ4A 09/23/201111R1

TRAINQE JCHRISTH 707

S4NVZ3ISAH4 ThYM

4aLvN6JS 10 Ld

2:14-cv-11700-PDB-MJH Doc # 1-9 Filed 04/29/14 Pg 9 of 13 Pg ID 139
DISABILITY CERTIFICATE

PATtENT OF INJURY /b /iL

DIAGNOSIS cecL i7

have examined andlor treated the above name patient for injury sustained in the aforementioned

accident As result of the injuries .1 have disabled the person front those activities that are marked

withanX

my opinion that the paent is disabled fron work other from /% to __________

The patient is able to return to empoyrnertt at this time but is restricted from regular work duties

from the date ofaccident until The restrictions include

Lifting objects that weigh more than ______ pounds

Excessive bending

Excessive twisting

Prolonged standing

Other ______ EWO As some housework may involve beading lifting isting and proloflged

standing as required by vacuurnir.g making beds washing floDrs sinks bathtubs and toilets moving

farniture picking up objects on the floor carrying garbage or groceries

AiNGFOR THE FAT ENTS PERSONAL NEEDS Which may involve bending lifting

twisting and prolonged standing as required by bathing the patient dressing the patient and lifting

objects

CAR1NG FOR THE PATIENTS CHILDREN Whih may involve bending lifting and

prolonged standingas required by changing childrens clothes bathinn children cooking For the

children war til the children feeding the children ceamng and straightening up after the children

DRIVING

SIGNATURE OF FHYSIQ ATELu

PHYSICIANS NAME ______

L/

2:14-cv-11700-PDB-MJH Doc # 1-9 Filed 04/29/14 Pg 10 of 13 Pg ID 140
Jan 19 UIV j4M Ro 9öfl

22TX86c a/il

DISABILITY CERTIFICATE

PATIENTNAME DATE OF INJURY 5jflJ9

DIAGNOSIS .LLJaJt --.---

have examind and/or cxeatcd the above name paticnt for injury sustaintd in the aforemcfflioned

accident As result ofthe injuries hay disabld the pcmon from those activUies that are marked

with an

ice ft is my opinion that the patient is disabled from work other from 16 /tt to ___________

.Z. The patient is able to return to employment at this time1 but restricted from regular work dutIes

from the date ofaccident until_ The rcstrktions include

_12 Lifting objecta that weigh more than ISpounds

_-t2xcessive bending

Excessive twisting

Prolonged standing

Other

QUSEWORK As some housework may invotvc bending lifting twisting and prolonged

Stan ng as required by vacuuming making beds washing floors sinks bathtubs and toileis moving

ftiinibwe picking up objects on the floor carrying garbageor groceries

CARING FOR THE PATIENTS PERSONAL NEEDS Which may involve bending lifting

twisting and pTOIOngCd standing as required by bathing the patent dressing the patient and lifting

objects

CARING FOR THE PATIENTS CHILDREN Which may involve bending lifting and

prolonged standing as required by changing childrens clothes bathing children1 cookIng for the

children watching the children feeding the children cleaning and straightening up after the children

DRWINC

SICNATURE OF PHYSICIAN

PHYSICIANS NAME

2:14-cv-11700-PDB-MJH Doc # 1-9 Filed 04/29/14 Pg 11 of 13 Pg ID 141
Jun 2@1U 229PM 4127

DISABILITY CERTIFICATE

PATIENT NAME DATE OF INJURY 423

DIAGNOSIS .4tAflco/ TP1O4Z4C4 Lvwt4gp

have examined andfor treated the above name patient for injury sustained in the aforementioned

accident As result ofthe injuries have disabled the person from those activities that are marked

with an

it is my opinion that the patientis disabled from work other from Q2J.Q to

____ The patient is able to return to employment at this time but is restricted from regular work duties

from Lile date ofaccident until The resirictions include

Lifting objects that weigh more than ______ pounds

Excessive bending

Excessive twisting

Prolonged standing

Other __________

\4IOUSEWORIC As some housework may involve bending lifting twisting and prolonged

standiitg as required by vacuuming making beds washing floors sinks bathtubs and toilets moving

fumihire picking up objects on the floorb carrying garbage or gróceries

CARING FOR TIlE PATIENTS PERSONAL NEEDS Which may involve bending lifting

Iw1 ing arid prolonged standing as required by bathing the patient dressing the patient and lifting

objects

____ CARING FOR TUE PATIENTS CHILDREN Which may involse bending lifting and

prolonged standing as required by changing childrens ctothes bathing children cooking for the

children watching the children1 feeding the children cleaning and straightening up after the children

25VINGt

SIGNATUROFPHYSlClAN DATE 620lO

PHYSICIANSNAME tw @wnDc_ --

2:14-cv-11700-PDB-MJH Doc # 1-9 Filed 04/29/14 Pg 12 of 13 Pg ID 142
DISABILITY CERTIFICATE

PATIENT NAME JITIIIIIITt DATE OF INJURY __________

DIAGNOSIS L4K/4cW 1ji4 442 have examined and/or treated the above name patient for injury sustained in the aforemcntioned

accident As result ofthe injuries have disabled the person from those activities that are marked

with an tX

.i It is ray opinion that the patient is disabled from work other from __________ to

___________

The patient is able to return to employment at this time but restricted from regular work duties

from the date olaccidcnt until _______ The restrictions include

Lifting objects that weigh more than pound

Excessive bending

Excessive twisting

Prolonged standing

Other _________

VIOIJSEWORK As some housework may involve bending lilting twisting and prolonged

standing as required by vacuuming making beds washing floors sinks bathtubs and toilets moving

ftsniiture picking up objects on the floor carrying garbage or groceries

J1ARING FOR THE PATIENTS PERSONAL NEEDS Which may involve bending lifting

twisting and prolonged standing as required by bathing the patient dressing the patient and lifting

objects

VCARJNG FOR THE PATIENTS CHILDREN Which may involve bending lifting and

prolonged standing as required by changing childrens clothes bathing children cooking for the

children watching the children feeding the children1 cleaning and straightening up after the children

DRIVING

SIGNATURE OF PHYSICIAN ____________________________ DATE _________

PHYSICIANS NAME

2:14-cv-11700-PDB-MJH Doc # 1-9 Filed 04/29/14 Pg 13 of 13 Pg ID 143