Aguilar v. Social Security Administration, Commissioner
MEMORANDUM OPINION. Signed by US Magistrate Judge T Michael Putnam on 6/2/2014. (MSN)
2014 Jun-02 PM 03:39
U.S. DISTRICT COURT
N.D. OF ALABAMA
UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
ANGELA KNIGHT AGUILAR,
CAROLYN W. COLVIN, ACTING
COMMISSIONER OF SOCIAL SECURITY
) Case Number: 6:13-cv-00966-JHE
Plaintiff Angela Knight Aguilar (“Aguilar”) seeks review, pursuant to 42 U.S.C. § 405(g),
§ 205(g) of the Social Security Act, of a final decision of the Commissioner of the Social Security
Administration (“Commissioner”), denying her application for a period of disability, disability
insurance benefits (“DIB”), and Supplemental Security Income (“SSI”). Aguilar timely pursued and
exhausted her administrative remedies. The case is therefore ripe for review under 42 U.S.C.
§§ 405(g), 1383(c)(3). The undersigned has carefully considered the record and, for the reasons
stated below, the Commissioner’s decision is AFFIRMED.2
Carolyn W. Colvin was named the Acting Commissioner on February 14, 2013. See
http://www.socialsecurity.gov/pressoffice/factsheets/colvin.htm (“On February 14, 2013, Carolyn
W. Colvin became the Acting Commissioner of Social Security.”). Under 42 U.S.C. § 405(g), “[a]ny
action instituted in accordance with this subsection shall survive notwithstanding any change in the
person occupying the office of Commissioner of Social Security or any vacancy in such office.”
Accordingly, pursuant to 42 U.S.C. § 405(g) and Rule 25(d) of the Federal Rules of Civil Procedure,
the Court has substituted Carolyn W. Colvin in the case caption above.
In accordance with the provisions of 28 U.S.C. § 636(c) and Federal Rule of Civil Procedure 73,
the parties have voluntarily consented to have a United States Magistrate Judge conduct any and all
proceedings, including trial and the entry of final judgment. (Doc. 12).
I. Factual and Procedural History
Aguilar was a forty-five year old female at the time of the Administrative Law Judge (“ALJ”)
decision. (Tr. 35). Aguilar has at least a high school education and previously worked as a plastics
trimmer/packer, a poultry trimmer, and a cashier. (Tr. 35, 59-60, 206).
Aguilar filed her application for a period of disability, DIB, and SSI on February 26, 2010,
alleging an initial onset date of February 5, 2010. (Tr. 76-77, 141-42, 148-55). The Commissioner
denied Aguilar’s application, (tr. 79-83), and Aguilar requested a hearing before an ALJ. (Tr. 94-95).
After a hearing, the ALJ denied Aguilar’s claim on December 15, 2011. (Tr. 9-24). Aguilar sought
review by the Appeals Council, but it declined her request on March 26, 2013. (Tr. 1-5). On that
date, the ALJ’s decision became the final decision of the Commissioner. On May 22, 2013, Aguilar
initiated this action. (See doc. 1).
II. Standard of Review3
The Court’s review of the Commissioner’s decision is narrowly circumscribed. The function
of this Court is to determine whether the decision of the Commissioner is supported by substantial
evidence and whether proper legal standards were applied. Richardson v. Perales, 402 U.S. 389,
390, 91 S. Ct. 1420, 1422 (1971); Wilson v. Barnhart, 284 F.3d 1219, 1221 (11th Cir. 2002). This
Court must “scrutinize the record as a whole to determine if the decision reached is reasonable and
supported by substantial evidence.” Bloodsworth v. Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983).
Substantial evidence is “such relevant evidence as a reasonable person would accept as adequate to
In general, the legal standards applied are the same whether a claimant seeks DIB or SSI. However,
separate, parallel statutes and regulations exist for DIB and SSI claims. Therefore, citations in this
opinion should be considered to refer to the appropriate parallel provision as context dictates. The
same applies to citations for statutes or regulations found in quoted court decisions.
support a conclusion.” Id. It is “more than a scintilla, but less than a preponderance.” Id. This Court
must uphold factual findings that are supported by substantial evidence. However, it reviews the
ALJ’s legal conclusions de novo because no presumption of validity attaches to the ALJ’s
determination of the proper legal standards to be applied. Davis v. Shalala, 985 F.2d 528, 531 (11th
Cir. 1993). If the Court finds an error in the ALJ’s application of the law, or if the ALJ fails to
provide the court with sufficient reasoning for determining the proper legal analysis has been
conducted, it must reverse the ALJ’s decision. Cornelius v. Sullivan, 936 F.2d 1143, 1145-46 (11th
III. Statutory and Regulatory Framework
To qualify for disability benefits and establish his or her entitlement for a period of disability, a claimant must
be disabled as defined by the Social Security Act and the Regulations promulgated thereunder.4
define “disabled” 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 (12) months.” 20
C.F.R. § 404.1505(a). To establish entitlement to disability benefits, a claimant must provide
evidence of a “physical or mental impairment” which “must result from anatomical, physiological,
or psychological abnormalities which can be shown by medically acceptable clinical and laboratory
diagnostic techniques.” 20 C.F.R. § 404.1508.
The “Regulations” promulgated under the Social Security Act are listed in 20 C.F.R. Parts 400 to
499, revised as of April 1, 2007.
The Regulations provide a five-step process for determining whether a claimant is
disabled. 20 C.F.R. § 404.1520(a)(4)(i-v). The Commissioner must determine in sequence:
whether the claimant is currently employed;
whether the claimant has a severe impairment;
whether the claimant’s impairment meets or equals an impairment listed
by the [Commissioner];
whether the claimant can perform his or her past work; and
whether the claimant is capable of performing any work in the national
Pope v. Shalala, 998 F.2d 473, 477 (7th Cir. 1993) (citing to the formerly applicable C.F.R. section),
overruled on other grounds by Johnson v. Apfel, 189 F.3d 561, 562-63 (7th Cir. 1999); accord
McDaniel v. Bowen, 800 F.2d 1026, 1030 (11th Cir. 1986). “Once the claimant has satisfied steps
One and Two, she will automatically be found disabled if she suffers from a listed impairment. If
the claimant does not have a listed impairment but cannot perform her work, the burden shifts to the
[Commissioner] to show that the claimant can perform some other job.” Pope, 998 F.2d at 477;
accord Foote v. Chater, 67 F.3d 1553, 1559 (11th Cir. 1995). The Commissioner must further show
such work exists in the national economy in significant numbers. Id.
IV. Findings of the Administrative Law Judge
After consideration of the entire record and application of the sequential evaluation process,
the ALJ made the following findings:
At Step One, the ALJ found Aguilar met the insured status requirements of the Social
Security Act through June 30, 2014, and that Aguilar had not engaged in substantial gainful activity
since February 5, 2010, the alleged onset date of her disability. (Tr. 14). At Step Two, the ALJ found
Aguilar has the following severe impairments: disorder of the back, headaches, obesity,
hypertension, affective mood disorder, and a personality disorder. (Id.). At Step Three, the ALJ
found Aguilar does not have an impairment or combination of impairments that meets or medically
equals one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (Tr. 15-17).
Before proceeding to Step Four, the ALJ determined Aguilar’s residual functioning capacity
(“RFC”), which is the most a claimant can do despite her impairments. See 20 C.F.R.
§ 404.1545(a)(1). The ALJ determined Aguilar has the RFC to perform sedentary work as defined
in 20 C.F.R. 404.1567(a) and 416.967(a), except that she can understand and remember simple, but
not detailed instructions; carry out simple instructions and sustain attention to simple/preferred tasks
for extended periods; would function best with her own work area/station with few distractions;
would function best with a familiar repetitive work routine, but should avoid rapid changes and
multiple demands; contact with the public should be non-intensive and limited; feedback should be
supportive; contact with coworkers should be casual; she could adapt to infrequent, well-explained
changes; contact with supervisors should be supportive and tactful; she is unable to work around
unprotected heights or dangerous or moving equipment; no ladders, ropes, or scaffolds. (Tr. 17-18).
At Step Four, the ALJ determined Aguilar could perform her past relevant work as a poultry
trimmer. (Tr. 31). At Step Five, the ALJ alternatively determined, based on Aguilar’s age,
education, work experience, and residual functional capacity, there are jobs that exist in significant
numbers in the national economy she could perform. (Tr. 22). Therefore, the ALJ determined
Aguilar has not been under a disability and denied her claim. (Tr. 23).
Although the Court may reverse a finding of the Commissioner only if it is not supported by
substantial evidence or because improper legal standards were applied, “[t]his does not relieve the
court of its responsibility to scrutinize the record in its entirety to ascertain whether substantial
evidence supports each essential administrative finding.” Walden v. Schweiker, 672 F.2d 835, 838
(11th Cir. 1982) (citing Strickland v. Harris, 615 F.2d 1103, 1106 (5th Cir. 1980)). The court,
however, “abstains from reweighing the evidence or substituting its own judgment for that of the
[Commissioner].” Id. (citation omitted).
Aguilar challenges the ALJ’s RFC determination contending the “credible medical evidence
of records establishes that the plaintiff has the residual functioning capacity for less than sedentary
work on a sustained basis, suffers severe and debilitating pain and also suffers severe and debilitating
emotional problems.” (Doc. 8 at 6). Despite Aguilar’s arguments to the contrary, substantial
evidence supports the ALJ’s determination Aguilar failed to demonstrate a disability.
The ALJ’s RFC Finding is Supported by Substantial Evidence
The medical evidence supports the ALJ’s RFC finding. A claimant’s RFC reflects the most
she can do despite her limitations.
See 20 C.F.R. §§ 404.1545(a)(1), 416.945(a)(1). The
determination of an RFC is an administrative assessment based on all the evidence of how a
claimant’s impairments and related symptoms affect her ability to perform work-related activities.
See Social Security Ruling (SSR) 96-8p, 1996 WL 374184, at *1-2. The final responsibility for
assessing a claimant’s RFC rests with the ALJ, who must based the assessment on the relevant
medical and other evidence. See 20 C.F.R. §§ 404.1527(e)(2), 404.1545(a)(3), 404.1546(c),
416.927(e)(2), 416.945(a)(3), 416.946(c). Relevant medical and other evidence includes medical
assessments, medical reports from treating and examining sources, and descriptions and observations
of a claimant’s limitations by the claimant and others.
See 20 C.F.R. §§ 404.1545(a)(3),
416.945(a)(3); SSR 96-8p, 1996 WL 374184 at *5.
Aguilar points to the following specific alleged errors with the ALJ’s RFC assessment.
Specifically, she contends (1) Dr. Lyman, a psychologist, stated Aguilar’s ability to respond
appropriately to supervision, co-workers, and job pressures in a work setting may be comproimsed
by her report of hallucinations; (Doc. . at 7), and (2) Dr. Zaremba’s assessment identified a RFC
from an exertional standpoint for less than sedentary work, some postural and manipulative
limitations and significant non-exertional limitations (id. at 7-8).5
Aguilar also contends that
although an x-ray of her lumbar spine showed moderate disc space narrowing at the L5-S1 level, the
SSA failed to have her examined by a medical doctor. (Id. at 6-7)
The medical evidence supports the ALJ’s RFC finding. As to Aguilar’s psychological
condition, the ALJ noted that Ruth Ann Lyman, Ph.D., conducted a consultative mental evaluation
of Aguilar on June 4, 2010. (Tr. 19, 370-73). On examination, Aguilar was neatly dressed and
interacted appropriately. (Tr. 371). She spoke at a normal pace and volume. (Id.). Aguilar’s mood
appeared anxious and negative and her affect was tense and constrained. (Tr. 19, 371). Dr. Lyman
noted Aguilar was attentive throughout the examination. (Tr. 371). Aguilar’s recent and remote
memory was intact, and she correctly performed simple arithmetic, but her fund of information,
Aguilar also argues that the only assessment that provides an opinion consistent with the ALJ’s
RFC finding is an evaluation from H.M. Spates dated June 16, 2010. (Doc. 8 at 10). Although
Aguilar argues M.H. Spates is not a medical doctor, she also concedes that, even if he were, the ALJ
did not consider this evidence in making his determination. (Id.).
concentration, focus, insight, and judgment were poor. (Tr. 371-72). Dr. Lyman noted Aguilar
reported having auditory and visual hallucinations. (Tr. 19, 372). Dr. Lyman stated that while
Aguilar was cooperative throughout the examination, her motivation was “inconsistent at best, if not
poor.” (Tr. 19, 373).
Dr. Lyman opined Aguilar could understand, carry out, and remember instructions. (Tr. 19,
373). She also opined Aguilar’s ability to respond appropriately to supervision, coworkers, and job
pressures in a work setting “may” be compromised by her report of hallucinations. (Tr. 373).
The ALJ gave significant weight to Dr. Lyman’s opinions as the ALJ found her findings were
based upon an examination and were consistent internally and with the record as a whole. (Tr. 21).
See 20 C.F.R. §§ 404.1527.(c)(3), (4), 416.927(c)(3), (4) (noting more weight is given an opinion
that is well explained and is consistent with the record); Richardson v. Perales, 402 U.S. 389, 401,
91 S. Ct. 1420 (1971) (a written report by a licensed physician/psychologist who has examined the
claimant may constitute substantial evidence supporting a finding by the hearing examiner adverse
to the claimant). Dr. Lyman’s examination and functional assessment provided substantial evidence
to support the ALJ’s RFC finding that Aguilar could understand, remember, and carry out simple
instructions and sustain attention. (Tr. 17-19). Her examination also provided substantial evidence
to support the ALJ’s RFC finding that Aguilar needed mild limits on the frequency and type of
contact she had with the public, co-workers, and supervisors. (Id.).
The ALJ also considered the opinion of Gloria Roque, Ph.D., a State agency psychological
consultant who conducted an assessment of Aguilar’s metnal functining in June 2010. (Tr. 375-91).
Based on her review of the record, Dr. Roque opined Aguilar could understand, carry out, and
remember simple instructions and sustain attention to perform simple/preferred tasks for extended
periods. (Tr. 391). She opined Aguilar would work best with her own work area/station with few
distractions; and would work best with familiar repetitive work routine, but she should avoid rapid
changes and multiple demands. (Tr. 391). Dr. Roque also opined Aguilar’s contact with the public
should be nonintensive/limited; her feed back should be supportive; and her contact with coworkers
should be casual. (Tr. 391). She opined Aguilar could adapt to infrequent, well-explained changes.
The ALJ noted that Dr. Roque did not examine Aguilar, but did consider the evidence in the
record. (Tr. 21, 389). The ALJ gave significant eight to Dr. Roque’s assessment as it was internally
consistent and consistent with the evidence as a whole. (Tr. 21). See 20 C.F.R. §§ 404.1527(e)(2)(i),
416.927(e)(2)(I) (State agency medical and psychological consultants are highly qualified and are
also experts in Social Security disability evaluation and their opinions must be considered and
weighed by the ALJ); SSR 96-6p, 1996 WL 374180, at *3 (opinion from State agency medical and
psychological consultants may be entitled to greater weight than the opinions of treating or
examining sources). Dr. Roque’s findings are consistent with the ALJ’s RFC findings, (tr. 17-18),
and provide substantial evidence to support the ALJ’s decision that Aguilar was not disabled. See
Forrester v. Comm’r of Soc. Sec., 455 Fed. Appx. 899, 902 (11th Cir. 2012) (“The ALJ clearly
articulated its reasons for giving significant weight to the non-examining physicians’ opinions, which
it stated that their opinions were more consistent with the medical evidence.”)
The ALJ further noted the record showed Aguilar’s psychological symptoms were controleld
when she took her medication. (Tr. 20). For example, in August 2010, Aguilar reported her Zoloft
was working well. (Tr. 398). On examination, Aguilar’s mood was normal. (Tr. 399). In April
2011, despite not taking her Zoloft, Aguilar’s mood ws normal. (Tr. 411, 413). In September 2011,
Aguilar reported she was doing “very well” on Cymbalta. (Tr. 405). Again, her mood was found
to be normal. (Tr. 406).
Aguilar cites Lamb v. Bowen, 847 F.2d 698 (11th Cir. 1988), and Sharfarz v. Bowen, 825
F.2d 278, 279-90 (11th Cir. 1987), and appears to argue Dr. Roque’s opinion is insufficient to
support the ALJ’s decision. (Doc. 8 at 8-14). Those cases involve situations where the ALJ gave
greater weight to the opinion of a non-examining source over a treating physician’s opinion. Here,
Aguilar has not submitted a treating source opinion of her functional capacities. Moreover, the
ALJ’s decision was not dependent solely on the report of the consultant; rather, the ALJ based his
decision on the record as a whole, including the opinion evidence, treatment records, and Aguilar’s
reports of her daily activities. (Tr. 17-21). Accordingly, the ALJ did not err in relying on Dr.
Roque’s assessment. See KDB ex rel. Bailey v. Soc. Sec. Admin., Comm’r., 444 Fed. Appx. 365, 367
(11th Cir. 2011).
As to Aguilar’s physicial condition, the ALJ also noted that on December 10, 2010, Aguilar
underwent a physical examination conducted by Jack Zaremba, M.D. (Tr. 20, 429-35). On
examination, Aguilar had no clubbing, cyanosis, or edema of her extremities, but had some tingling
and pain in her hands. (Tr. 20, 430). She had full range of motion in her back and no spasm. (Tr.
20, 430). Aguilar’s grip was “5/5" (fully intact). (Tr. 430). She walked slowly and stood normally.
Concurrently with the examination, Dr. Zaremba completed a medical source statement in
which he opined Aguilar could lift ten pounds occasionally and five pounds frequently; sit six hours
in an eight-hour day; stand or walk up to two hours in an eight-hour day; rarely bend, stoop, or push
or pull with her legs; never operate motor vehicles, work with or around hazardous machinery, or
climb stairs, ladders or balance. (Tr. 434). He opined Aguilar would be unable to work due to pain.
With the exception of his pain assessment, the ALJ gave significant weight to Dr. Zaremba’s
assessment of Aguilar’s limitations as he found it was internally consistent and well-explained. (Tr.
20-21). See 20 C.F.R. §§ 404.1527(c)(3), (4), 416.927(c)(3), (4); Perales, 402 U.S. at 401, 91 S. Ct.
1420. Dr. Zaremba’s assessment provides substantial evidence to support the ALJ’s RFC finding.
For example, Dr. Zaremba opined Aguilar could perform sedentary work. (Tr. 434). See 20 C.F.R.
§§ 404.1567(a), 416.967(a) (defining sedentary work). Like Dr. Zaremba, the ALJ found Aguilar
should not work around dangerous or moving equipment, ladders, ropes, or scaffolds. (Tr. 18, 434).
The ALJ properly rejected Dr. Zaremba’s opinion that Aguilar’s pain was disabling. (Tr. 20).
The ALJ was under no obligation to adopt the conclusion of Dr. Zaremba becaues he was not a
treating source. See 20 C.F.R. §§ 404.1527(c)(2), 416.927(c)(2); see also McSwain v. Bowen, 814
F.2d 617, 619 (11th Cir. 1987) (opinions of one-time examiners are not entitled to deference because
they are not treating physicians). However, the ALJ was required to evaluate Dr. Zaremba’s opinion
in accordance with the regulations, which identify the factors to be considered in weighing a medical
source’s opinion. See 20 C.F.R. §§ 404.1527(c), 416.927(c); see Crawford v. Comm’r of Soc. Sec.,
363 F.3d 1155, 1160 (11th Cir. 2004) (the weight to be afforded a medical opinion regarding the
nature and severity of a claimant’s impairment depends, among other things, upon the examining
and treating relationship the medical source had with the claimant, the evidence the medical source
presents to support the opinion, how consistent the opinion is with the record as a whole, and the
specialty of the medical source).
The ALJ rejected Dr. Zaremba’s pain assessment as not supported by his own examination
findings. (Tr. 20). See 20 C.F.R. §§ 404.1527(c)(3); 416.927(c)(3). For example, the ALJ noted
that although Dr. Zaremba reported Aguilar’s gait was slow, he also reported she had a normal stance
and could squat halfway. (Tr. 20, 430). Despite complaints of pain, Dr. Zaremba report Aguilar had
full range of motion in her back and no muscle spasms. (Tr. 430). Aguilar also complained of pain
on full extension of her left leg. (Tr. 20, 430). Given the paucity of descriptions of severe pain by
Dr. Zaremba, the ALJ properly reasoned Dr. Zaremba’s examination report did not support his
opinion that Aguilar had disabling pain. (Tr. 20). See Ogranaja v. Comm’r of Soc. Sec., 186 Fed.
Appx. 848, 850 (11th Cir. 2006) (ALJ did not err by rejecting the opinion of an examining physician
that was based on subjective complaints without significant clinical findings).
The ALJ also noted the medical records did not support Aguilar’s allegations of pain. (Tr.
20). Physical examinations performed at Capstone Rural Health Center between February 2010 and
September 2011 consistently showed her musculoskeletal examination was normal, (tr. 20-21, 258,
399, 406, 409, 412-13, 417, 419-20). In June 2010, Aguilar stated she was doing well. (Tr. 298).
In March 2011, Aguilar denied feeling “tired or poorly.” (Tr. 414). In July 2011, Aguilar denied any
problems or concerns. (Tr. 408).
The ALJ also considered Aguilar’s daily activities. See Macia v. Bowen, 829 F.2d 1009, 1012
(11th Cir. 1987) (the ALJ may consider a claimant’s daily activities when determining RFC).
Despite Aguilar’s allegations of disabling symptoms, the ALJ reasoned her daily activities were not
consistent with disability. (Tr. 21, 196-200). Aguilar reported she spent time on her friend’s
computer, watched television, washed dishes, prepared meals, did household chores, cared hor her
friend’s pets, and had no problems with personal care. (Tr. 26, 196-200). Substantial evidence
supports the ALJ’s RFC finding.
To the extent Aguilar argues the SSA should have order an examination by a medical doctor
following her May 25, 2010 x-ray, the record includes (and the ALJ considered) medical records
from Aguilar’s visit to Capstone Rural Health Center on June 18, 2010. (Tr. 20, 395-99). These
records indicate, that although she reported chronic pain, Aguilar reported she was doing well and
denied feeling tired or poorly; hip, thigh, knee, or leg symptoms; muscle aches; or motor or sensory
disturbances. (Id.). Aguilar’s physical examination was normal with no problems noted with her
musculoskeletal or neurological systems and no changes were made to her treatment or medication
plan. (Id.). Accordingly, Aguilar’s contention the SSA should have ordered a physical examination
is without merit.
To the Extent the ALJ Found Aguilar Could Perform Her Past Relevant Work,
That Finding is Inconsistent with the RFC but is Harmless Error
The ALJ’s finding that Aguilar could perform her past relevant work as poultry trimmer is
inconsistent with his finding that she was limited to sedentary work. The VE testified a person who
is limited to sedentary work could not perform Aguilar’s past relevant work. (Tr. 61). Any error
here, however, was harmless because, upon proper questioning, the VE identified sedentary work
Aguilar could perform, (tr. 60-62), and the ALJ found that considering her age, education, work
experience and residual functioning capacity, there are jobs that exist in significant numbers in the
national economy that Aguilar could perform. (Tr. 22).
Substantial evidence supports the ALJ’s RFC finding and hypothetical questions to the VE,
and Aguilar fails to prove she cannot perform the jobs identified by the VE. See Doughty v. Apfel,
245 F.3d 1274, 1278 n.2 (11th Cir. 2001) (noting the claimant must prove he is unable to perform
the jobs the Commissioner lists); Jones v. Apfel, 190 F.3d 1224, 1228 (11th Cir. 1999) (same).
Aguilar fails to prove she is more limited than the ALJ found. The ALJ properly considered the
relevant evidence and properly performed his duty as the trier of fact of weighing and resolving any
conflicts in the evidence. See Phillips, 357 F.3d at 1240 n.8. The ALJ’s findings provide a thorough
and detailed discussion of Aguilar’s medical history of record, testimony, and the record as a whole.
The ALJ’s consideration of Aguilar’s impairments is consistent with the applicable regulations and
case law and substantial evidence supports his conclusion Aguilar was not disabled within the
meaning of the Social Security Act.
Because the Commissioner’s decision is based on substantial evidence and the ALJ applied
proper legal standards, it is AFFIRMED and this action will be DISMISSED WITH PREJUDICE.
A separate order will be entered.
DONE this 2nd day of June, 2014.
T. MICHAEL PUTNAM
U.S. MAGISTRATE JUDGE
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