Johnson v. Kijakazi ( 2024 )

1 Marc V. Kalagian Attorney at Law: 4460 2 Law Offices of Lawrence D. Rohlfing, Inc., CPC 12631 East Imperial Highway Suite C-115 3 Santa Fe Springs, CA 90670 Tel.: (562) 868-5886 4 Fax: (562) 868-8868 E-mail: marc.kalagian@rksslaw.com 5 Leonard Stone 6 Attorney at Law: 5791 Shook & Stone 7 710 South 4th Street Las Vegas, NV 89101 8 Tel.: (702) 385-2220 Fax: (702) 384-0394 9 E-mail: Lstone@shookandstone.com 10 Attorneys for Plaintiff Torrell Johnson 11 12 UNITED STATES DISTRICT COURT 13 DISTRICT OF NEVADA 14 15 TORRELL JOHNSON, ) Case No.: 2:23-cv-01251-BNW ) 16 Plaintiff, ) STIPULATION AND PROPOSED ) ORDER FOR THE AWARD AND 17 vs. ) PAYMENT OF ATTORNEY FEES ) AND EXPENSES PURSUANT TO 18 MARTIN O'MALLEY, ) THE EQUAL ACCESS TO JUSTICE Commissioner of Social Security, ) ACT, 28 U.S.C. § 2412(d) AND 19 ) COSTS PURSUANT TO 28 U.S.C. § Defendant. ) 1920 20 ) ) 21 22 TO THE HONORABLE BRENDA WEKSLER, MAGISTRATE JUDGE 23 OF THE DISTRICT COURT: 24 IT IS HEREBY STIPULATED, by and between the parties through their 25 undersigned counsel, subject to the approval of the Court, that Torrell Johnson 26 (“Johnson”) be awarded attorney fees in the amount of SIX THOUSAND TWO 1 HUNDRED FIFTY-TWO dollars and EIGHTY FOUR cents ($6,252.84) under the 2 Equal Access to Justice Act (EAJA), 28 U.S.C. § 2412(d), and costs in the amount 3 of FOUR HUNDRED TWO dollars ($402.00) under 28 U.S.C. § 1920. This 4 amount represents compensation for all legal services rendered on behalf of 5 Plaintiff by counsel in connection with this civil action, in accordance with 28 6 U.S.C. §§ 1920; 2412(d). 7 After the Court issues an order for EAJA fees to Johnson, the government 8 will consider the matter of Johnson's assignment of EAJA fees to Marc Kalagian. 9 The retainer agreement containing the assignment is attached as exhibit 1. 10 Pursuant to Astrue v. Ratliff, 130 S.Ct. 2521, 2529 (2010), the ability to honor the 11 assignment will depend on whether the fees are subject to any offset allowed under 12 the United States Department of the Treasury's Offset Program. After the order for 13 EAJA fees is entered, the government will determine whether they are subject to 14 any offset. 15 Fees shall be made payable to Johnson, but if the Department of the 16 Treasury determines that Johnson does not owe a federal debt, then the government 17 shall cause the payment of fees, expenses and costs to be made directly to Law 18 Offices of Lawrence D. Rohlfing, Inc., CPC, pursuant to the assignment executed 19 by Johnson.1 Any payments made shall be delivered to Law Offices of Lawrence 20 D. Rohlfing, Inc., CPC. Counsel agrees that any payment of costs may be made 21 either by electronic fund transfer (ETF) or by check. 22 This stipulation constitutes a compromise settlement of Johnson's request for 23 EAJA attorney fees, and does not constitute an admission of liability on the part of 24 25 1 The parties do not stipulate whether counsel for the plaintiff has a cognizable lien under federal law against the recovery of EAJA fees that survives the Treasury 26 1 || Defendant under the EAJA or otherwise. Payment of the agreed amount shall 2 || constitute a complete release from, and bar to, any and all claims that Johnson 3 || and/or Marc Kalagian including Law Offices of Lawrence D. Rohlfing, Inc., CPC, 4 ||may have relating to EAJA attorney fees in connection with this action. 5 This award is without prejudice to the rights of Marc Kalagian and/or the 6 || Law Offices of Lawrence D. Rohlfing, Inc., CPC, to seek Social Security Act 7 || attorney fees under 42 U.S.C. § 406(b), subject to the savings clause provisions of 8 || the EAJA. 9 || DATE: October 2, 2024 Respectfully submitted, 10 LAW OFFICES OF LAWRENCE D. ROHLFING, INC., CPC 11 /S| WareV. Kalagian BY: 12 Marc V. Kalagian 1 Attorney for plaintiff 3 TORRELL JOHNSON 14 I DATE: October 2, 2024 JASON M. FRIERSON 5 United States Attorney 16 17 /s/ Yukie Cummings 18 JULIE CUMMINGS Special Assistant United States Attorney 19 Attorneys for Defendant MARTIN O'MALLEY, Commissioner of Social 20 Security (Per e-mail authorization) 21 ORDER 22 Approved and so ordered: 23 DATE: 10/4/2024 Ls gun lea Are fern 25 THE HONORABLE BRENDA WEKSLER UNITED STATES MAGISTRATE JUDGE 26 1 DECLARATION OF MARC V. KALAGIAN 2 I, Marc V. Kalagian, declare as follows: 3 1. I am an attorney at law duly admitted to practice before this Court in this 4 case. I represent Torrell Johnson in this action. I make this declaration 5 of my own knowledge and belief. 6 2. I attach as exhibit 1 a true and correct copy of the retainer agreement with 7 Torrell Johnson containing an assignment of the EAJA fees. 8 3. I attach as exhibit 2 a true and correct copy of the itemization of time in 9 this matter. 10 I declare under penalty of perjury that the foregoing is true and correct to the 11 best of my knowledge and belief. 12 Executed this October 2, 2024, at Santa Fe Springs, California. 13 14 /s/ Marc V. Kalagian 15 _________________________ Marc V. Kalagian 16 17 18 19 20 21 22 23 24 25 26 1 PROOF OF SERVICE 2 STATE OF CALIFORNIA, COUNTY OF LOS ANGELES 3 I am employed in the county of Los Angeles, State of California. I am over 4 the age of 18 and not a party to the within action. My business address is 12631 5 East Imperial Highway, Suite C-115, Santa Fe Springs, California 90670. 6 On this day of October 3, 2024, I served the foregoing document described 7 as STIPULATION FOR THE AWARD AND PAYMENT OF ATTORNEY FEES 8 AND EXPENSES PURSUANT TO THE EQUAL ACCESS TO JUSTICE ACT, 9 28 U.S.C. § 2412(d) AND COSTS PURSUANT TO 28 U.S.C. § 1920 on the 10 interested parties in this action by placing a true copy thereof enclosed in a sealed 11 envelope addressed as follows: 12 Mr. Torrell Johnson 9785 Skyscape Ave. 13 Las Vegas, NV 89178 14 I caused such envelope with postage thereon fully prepaid to be placed in the 15 United States mail at Santa Fe Springs, California. 16 I declare under penalty of perjury under the laws of the State of California 17 that the above is true and correct. 18 I declare that I am employed in the office of a member of this court at whose 19 direction the service was made. 20 Marc V. Kalagian ___ /s/ Marc V. Kalagian___________ 21 TYPE OR PRINT NAME SIGNATURE 22 23 24 25 26 1 CERTIFICATE OF SERVICE FOR CASE NUMBER 2:23-CV-01251-BNW 2 I hereby certify that I electronically filed the foregoing with the Clerk of the 3 4 Court for this court by using the CM/ECF system on October 3, 2024. 5 I certify that all participants in the case are registered CM/ECF users and 6 that service will be accomplished by the CM/ECF system, except the plaintiff 7 served herewith by mail. 8 9 /s/ Marc V. Kalagian _______________________________ 10 Marc V. Kalagian 11 Attorneys for Plaintiff 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 SOCIAL SECURITY REPRESENTATION AGREEMENT This agreement was made on August 9, 2021, by and between the Law Offices of Rohlfing & Kalagian, LLP referred to as attorney and Mr. Torrell Johnson, S.S.N. ‘8850, herein referred to as Claimant. 1. Claimant employs and appoints Law Offices of Rohlfing & Kalagian, LLP to represent Claimant as Mr. Torrell Johnson’s Attorneys at law in a Social Security claim regarding a claim for disability benefits and empowers Attorney to take such action as may be advisable in the judgment of Attomey, including the taking of judicial review. 2. In consideration of the services to be performed by the Attorney and it being the desire of the Claimant to compensate Attorney out of the proceeds shall recetve 25% of the past due benefits awarded by the Social Security Administration to the claimant or such amount as the Commissioner may designate under 42 U.S.C. § 406(a)(2)(A) which is currently $6,000.00, whichever is smaller, upon successful completion of the case at or before a first hearing decision from an ALJ. If the Claimant and the Attorney are unsuccessful in obtaining a recovery, Attorney will receive no fee. This matter is subject expedited fee approval except as stated in 43. 3. The provisions of § 2 only apply to dispositions at or before a first hearing decision from an ALJ. The fee for successtul prosecution of this matter is 25% of the past due benefits awarded upon reversal of any unfavorable ALJ decision for work before the Social Security Administration. Attorney shall petition for authorization to charge this fee in compliance with the Social Security Act for all time whether exclusively or not committed to such representation. 4. If this matter requires judicial review of any adverse decision of the Social Security Administration, the fee for successful prosecution of this matter is a separate 25% of the past due benefits awarded upon reversal of any unfavorable ALJ decision for work before the court. Attomey shall seek compensation under the Equal Access to Justice Act and such amount shall credit to the client for fees otherwise payable for that particular work. Client shall endorse such documents as are needed to pay Attorney any amounts under the EAJA and assigns such fee awards to Attomey. 5. Claimant shall pay all costs, including, but not limited to costs for medical reports, filing fees, and consultations and examinations by experts, in connection with the cause of action. 6. Attorney shall be entitled to a reasonable fee; notwithstanding the Claimant may discharge or obtain the substitution of attorneys before Attorney has completed the services for which he is hereby employed. 7. Attorney has made no warranties as to the successful termination of the cause of action, and all expressions made by Attorney relative thereto are matters of Attorney's opinion only. 8. This Agreement comprises the entire contract between Attomey and Claimant. The laws of the State of California shall govern the construction and interpretation of this Agreement except that federal law governs the approval of fees by the Commissioner or a federal court. Business and Professions Code § 6147(a)(4) states “that the fee is not set by law but is negotiable between attorney and client.” 9. Attomey agrees to perform all the services herein mentioned for the compensation provided above. 10. Client authorizes attorney to pay out of attorney fees and without cost to chent any and all referral or association fees to James T. Crytzer, not to exceed 25% of fees. 11. The receipt from Claimant of — none is hereby acknowledged by attorney to be placed in trust and used for costs. It is so agreed. . Z a [ f, le] WMareV. Kalagian / r. Torrell Johfson Law Offices of Rohlfing & Kalagian, LLP Mare V. Kalagian Pie MEUGGIE tdaac NAME Mr. Torrell Johnson SSN 439-53-8850 Birthday 12/30/1972 SSA USE ONLY NUMBER HOLDER (If other than above} NAME SSN AUTHORIZATION TO DISCLOSE INFORMATION TO THE LAW OFFICES OF ROHLFING & KALAGIAN, LLP ** PLEASE READ THE ENTIRE FORM, BOTH PAGES, BEFORE SIGNING BELOW ** I voluntarily authorize and request disclosure {including paper, oral, and electronic interchange): OF WHAT All my records pertaining to workers' compensation benefits; state disability benefits; or other public benefit that affects the receipt of Social Security benefits. This includes specific permission to release: 1. All records and other information regarding my treatment, hospitalization, and outpatient care for my impairment(s} including, and not limited to: -- Psychological, psychiatric or other mental impairment(s} (excludes “psychotherapy notes” as defined in 45 CFR 164.501} - Drug abuse, alcoholism, or other substance abuse Sickle cell anemia -- Records which may indicate the presence of a communicable or venereal disease which may inciude, but are not limited to, diseases such as hepatitis, syphilis, gonorrhea and the human immunodeficiency virus, also known as Acquired Immune Deficiency Syndrome (AIDS); and tests for HIV. -- Gene-+elated impairments (including genetic test results) 2. Information about how my impairment(s) affects my ability to complete tasks and activities of daily living, and affects my ability to work. 3. Copies of educational tests or evaluations, including Individualized Educational Programs, triennial assessments, psychological and speech evaluations, and any other records that can help evaluate function; also teachers’ observations and evaluations 4, Information created within 12 months after the date this authorization is signed, as well as past information. FROM WHOM THIS BOX TO BE COMPLETED BY SSA/DDS (as needed) Additional information to identify the subject (e.g., other names used), the specific source, or the material fo be disclosed: Ali medical sources (hospitals, clinics, labs, physicians, psychologists, etc.) including mental health, carrectional, addiction treatment, and VA health care facilities educational sources (schools, teachers, records administrators, counselors, etc.} = Social Workers/rehabilitation counselors Consuiting examiners used by SSA * Employers Others who may know about my candition (family, neighbors, friends, public officials) TO WHOM Law Offices of Rohlfing & Kalagian, LLP including any employee thereof or photocopy service retained. PURPOSE Determining my eligibility for benefits, including looking at the combined effect of any impairments that by themse!ves would not meet SSA's definition of disability: and whether | can manage such benefits. □□ Determining whether | arm capable of managing benefits ONLY (check only if applies) EXPIRES WHEN This authorization is good for 12 months from the date signed (below at my signature) . | authorize the use of a capy (including electronic copy) of this form for the disclosure of the information described above. . understand that there are some circumstances where this information may be redisclosed to other parties (see page 2 far details). . | may write to Rohlfing & Kalagian, LLP and my sources to revoke this authorization at any time (see page 2 for details). . Rohifing & Kalagian, LLP will give me a copy of this form if | ask; | may ask the source to allow me to inspect or get a copy of the material ta be disclosed. . | have read both pages of this form and agree to the disclosures above from the types of sources listed. INDIVIDUAL authorizing disclosure IF not signed by subject of disclosure, specify basis for authority to sign SIG [} Parent of minor L] Guardian CI Other personal representative (explain) , LA, (Parent/quardian sign here if two > . Aor ee 2 £ signatures required by State law Date Signed / “ Street Address Df: (gf Lo24 9795 Skyscape Ave. Phone Number area code} City State ZIP 808) 354-7787 Las Vegas NV 89178 WITNESS i know the person signing this form or am satisfied of this person's identity: _ IF needed, second witness sign here (e.g., if signed with “X” above) SIGN > sion > Phane Number (or Address) Phone Number (or Address) This general and special authorization to disclose was developed to comply with the provisions regarding disclosure of medical, educational, and other information under P.L. 104-191 (HIPPA’); 45 CFR parts 160 and 164; 42 U.S. Cada section 290dd-2; 42 CFR part 2; 38 U.S. Code section 7332, 38 CFR 1.475; 20 U.S. Code section 1232g (“FERPA’); 34 CFR parts 99 and 300, and State law. _ SECHON five, JO VER ee EE ee eee eee Page 7 of 2 A MLSE TUT UL LIMES tld TO: Social Security Administration _Mr, Torrell Johnson {2/30/1972 439-53-8850 Name Date of Birth Social Security Number I authorize the Social Security Administration to release information or records about me to: NAME ADDRESS I want this information released because: (There may be a charge for releasing imformation.) Please release the following information: Social Security Number Identifying information {includes date and place of birth, parent's names) Monthly Social Security benefit amount Monthly Supplemental Security Income payment amount information about benefits/payments | received from 0 Information about my Medicare claim/coverage from to (specify) _ __ □□□□□□□ Medical records Record(s) from my file (specify) “Other(specify) I am the individual to whom the information/record applies or that person's parent (if a minor) or legal guardian. I know that if | make any representation which I know is false to obtain information from Social Security records, I could be punished by a fine or imprisonment or both. Signature: if D> (Show signafires, xfames, and addresdes of nwo people if signed by a mark.) Date: ‘ff 77 Relationship: SSA-3288 (5-2007) EF (5-2007) (Do not use this form for objecting to a recommended ALJ decision.) See Privacy Act Take or matt. original and all copies to vour focal Soctat Security affice, Notice on Rev erse the Veterans dffuirs Regional Office in Manila or aay CS. Foreign Service past) |. CLAIMANT 2. WAGE EARNER, IF DIFFERENT Torrell Johnson 3, SOCLAL SECURITY CLAIM NUMBER 4. SPOUSE'S NAME AND SOCLAL SECURITY NUMBER {Cemplete ONLY in Supplemental Security Income Cases) 5. [request that the Appeals Council review the Administrative Law Judge's action on the above claim because: Please see the attached letter. ADDITIONAL EVIDENCE If you have additional evidence, submut it with this request for review. Tf you need additional time te submit evidence or legal argument, you must request an extension of time in writing now. If you request an extension of time, you should explain the reason(s) you are unable to submit the evidence or legal argument now. If you neither submit evidence or legal argument now nor within any extension of tune the Appeals Council grants, the Appeals Council will take its action based on the evidence of record. IMPORTANT: Write your Social Security Ciaim Number on any letter or material you send us. SIGNATURE BLOCKS: You should complete No. 6 and your representative (if any} should complete No. 7. IF you are represented and your representative 15 not available to complete this form, you should alse print his or her name, address, ete. in Na. 7 DATE fd ATTORNEY C1 NON-ATTORNEY 6. CLAIMANT'S SIGNATURE tol hg) 7, REPRESENTATIVE'S SIGNATURE ie G □□□ ain Kiedis PRINT NAME PRINT NAME . Mr. Torrell Johnson Marc V. Kalagian ADDRESS ADDRESS 9785 Skyscape Ave. 211 East Ocean Boulevard, Suite 420 (CITY, STATE, ZIP CODE} (CITY, STATE, ZIP CODE) Las Vegas, NV 89178 Long Beach CA, 90802 TELEPHONE NUMBER (INCLUDE AREA CODE) TELEPHONE NUMBER{INCLUDE AREA CODE) (808) 354-7787 (562) 437-7006 THE SOCIAL SECURITY ADMINISTRATION STAFF WILL COMPLETE THIS PART &. Request received for the Social Security Administration on __ by: (Date) (Print Name) {Title} (Address) Servicing FO Code PO Code 9 request for review received within 65 days of the ALJ'S Decision/Dismissal? 1 Yes C1 No 10. checked: (1} attach claimant's explanation for delay; and (2) attach copy of appcintment notice, letter or other pertinent material or information in the Social Security Office. Ll. Check one: CJ Initial Entitlement 12. Check all claim types that apply: (J Termination or other CJ Retirement or survivers Day. (RST LJ Disability - Worker DIWC C] Disability - Widow/er) { ) C1 Disability - Child (DIWW) C1 SSI Aged (DWC) {1 SSI Blind (SSTA} APPEALS COUNCIL (SSI Disability (SSIB) OFFICE OF HEARINGS AND APPEALS, SSA (LJ Health Insurance - Pan A (SSI $107 Leesburg Pike CO Heaith Insurance - Part B (HIA) FALLS CHURCH, VA 22041-3255 L Title Only (HIB) () Title VIIVTutke XVI (SVB) CJ Other -- Specity: (SVBSSD Form HA-520-U5 (39-2001) EF (4-2002) rm SSA-1696 (08-2020) UF Prior Editions Page 3 of Security Administration, NO. □□□□□□□□ Claimant's Social Security Number Appointed Representative's Rep ID 439-53-8850 277Q25RLNM Appointment □□□ Representative Section 1 - Claimant's Information Name Last Name rrell Johnson Address 85 Skyscape Ave. State ZIP/Postal Code Country — if outside the U.S Vegas NV 89178 one Number Alternate Phone Number (Optional) 354-7787 Code Phone Number Country/Area Code | Phone Number Number Halder's Information (Complete when applicable) claim is based on another person’s work or earnings (e.g., spouse or parent). This person’s infarmation is from mine. Holder’s Social Security Number Section 2 - Disclosure (Claimant Only) By selecting this box, |, the claimant listed in Section 1, whose signature appears in Section 8, authorize SSA to release information in relation to my pending claim(s} or asserted right(s) to designated associates who □□□□□□□ administrative duties (e.g., clerks, assistants), partners, or parties under contractual arrangements for or with my representative. (The appointed representative's partners, associates, delegates and designees must be prepared to provide information in order to be authenticated.) Section 3 - Principal Representative (Claimant only — Complete when applicable) ave appointed before, or appoint now, more than one representative. | ask SSA to make contacts ar send to this individual. My principal representative is: Marc V. Kalagian _ SSA-1696 (08-2020) UF Page 4 of Claimant's Social Security Number Appointed Representative's Rep ID 439-53-8850 277Q25RLNM Section 4 - Representative's Information (Claimant and Representative} presentatives who are eligible and seek direct payment of their fee must register and receive a Rep ID before appointment. For more information about registration visit us on-line at www.socialsecurity.gov/ar, contact u 1-800-772-1213 (TTY 1-800-325-0778}, or visit your local Social Security office. st Name Initial Last Name Kalagian Address 1 East Ocean Boulevard, Suite 420 □□ [State ~=——«dY:~Sts«é2IP/ Postal Code i Country — if outside the Beach CA 90802 | U.S. one Number Alternate Phone Number (Optional) 437-7006 untry/Area Cade Phone Number Country/Area Code Phone Number Section 5S - Representative's Status, Affiliations, and Certifications (Representative Only} presentative's Status Part A - Type of Representative (Representatives have a duty to keep their information an attorney (SSA law states that an attorney is someone in good standing who has the right to practice la before a court of a State, Territory, District, or island possession of the United States, or before the Supreme Court or a lower Federai court of the United States.) | am a non-attorney eligible for direct payment (SSA law requires that non-attorneys meet certain criteria to qualify for direct payment. Refer to our website at www.ssa.gov/representation for criteria). lama non-attorney not eligible for direct payment. | work for non-profit organization (e.g. a law clinic or state legal aid) Representative's Status Part B — Disqualification now or have previously been disbarred or suspended from a court ar bar ta which | was previously admitted ctice law. Yes No m now or have previously been disqualified from participating in or appearing before a Federal program or ency. Yes No (08-2020) UF □□□□ Claimant’s Social Security Number Appointed Representative’s Rep ID 439-53-8850_ 277025RLNM Section 5 — Continued (Representative Only) Information are representing the claimant(s) as a partner or employee of a business entity, firm or other arganization you may provide your Identification Number (FIN) here, if one exists for tax purposes. This number is not your Social Security Number (SSN). This is tax identification number. (Da not complete this section if you do not qualify for direct payment.) Name (Enter the full name of the business, entity, firm or organization with which you want to be affiliated representing this claim) & Kalagian, LLP presentative’s Business Address [if different than mailing address) State ZIP/Postal Code outside theU.S. Representative’s Certifications this appaintment and certify the following: e understand and agree that | will comply with 5SA's laws and rules on the representation of parties, including the Rules of Conduct and Standards of Responsibility for Representatives; | will not charge, collect, or retain a fee for representational services that SSA has not approved or that is more than SSA approved unless a regulatory exclusion applies. ¢ understand that if | fail to comply with any of SSA's laws and rules | may be suspended or disqualified as a representative befo =| will not disclose any information to any unauthorized party without the claimant's specific written consent. e currently suspended or prohibited, for any reason, from practicing before the Social Security Administration. * lamnot disqualified from representing the claimant as a current or former officer ar employee of the United States. | accept appointment as the representative for the claimant named in Section 2 of this form in connection with the claims and asserted rights described in Section 6 of this farm. « |agree that a copy of this signed form SSA-1696 will have the same force and effect as the original. | declare under penalty of perjury that | have examined all of the information on this form and on all accompanying statements forms, including any information, attestations and certifications provided to SSA in registration, and that they are all currently true and correct to the best of my knowledge. intend to seek direct payment of the authorized fee on this claim - |have registered for and obtained a Rep ID, and my registration information is up-to-date. | have provided up-to-date information on my registration concerning whether | have been suspended or prohibited fram practice before $SA or any other Federal program or agency, disbarred or suspended by a court or bar, and convicted of a violation under Section 206 or 1631{d} of the Sociat Security Act. } CERTIFY TO ALL OF THE ABOVE MVK (Representative’s initials) rm SSA-1696 (08-2020) UF □□□□□□ Claimant's Social Security Number Appointed Representative's Rep ID 439-53-8850 277Q25RLNM Section 6 - Claim Type (C/aimant or Representative) the individual named in Section 4 to act as my representative in connection with my claim(s) or asserted right(s) under Title Title XVI {SSI}, Title XVIII (Medicare Coverage}, and Title VIII (SVB) of the Social Security Act, as presently amended, specifically for issues identified below: (Check all that apply) [| claim/Appeal for Title I! Disability Benefits [ | Claim/Appeal for Title XVI Disability Benefits x] Concurrent Title Il and Title XVI Disability Benefits Claim/Appeal for Retirement Benefits Claim/Appeal fer Title XVIII (Medicare}, (Special Veteran’s Benefits) Continuing Disability Review (CDR) Post-Entitlement Issue {a new issue you raise after eligibility for other benefits} (E.g., benefit amount, month of entitlement, representative payee, suspension, termination, overpayment) Section 7 - Fee Arrangement (Representative Only) one box below: | will request a fee and direct payment of this fee. Select this box if you are eligible for direct payment and want us to withhold a portion of the past-due benefits to pay you the fee we may authorize. (We must authorize the fee.) I will request a fee but not direct payment. Select this box if you are not eligible for direct payment from the past-due benefits, or | you do not want direct payment. You must collect any fee we may authorize on your own. {We must authorize the fee.) I waive the right to receive a fee from the claimant, any auxiliary beneficiaries or any other individual. Select this box if you certif that an entity, or a Federal, state, county, or city government agency will pay the fee and any expenses from its funds. The ciaiman auxiliary beneficiaries, or other individuals must not be liable for the fee, directly ar indirectly, in whole ar in part, or any expenses. (We do not need to authorize the fee if all requiatary conditions apply.) I waive the right to a fee. Section 8 - Signatures (Claimant and Representative} Signature Date August 9, 2021 Signature, 2g: ps Date 44 iol 49 August 9, 2021 fF nt Intake Sheet Attorney: Modify this as needed Date Form Completed: OF AX td gs Information □ ager Parent or Guardian(if Minor) _ 7745. Stego € (der. Zip Code: - Estado, Zona Postal A #t Se 4 ag ff7ed ada 7S Telephone: Cellular Telephone: 35 777 7 il: Ach Sy TG L@ Ganda [a □ Security Number AIRF KS YAO Date of Birth /v-f79 del seguro social Fecha de nacimiento Status/Estado Civil: Single/Soltero/a Married/Casado/a LI Divorced/Divorciado/a L] Other : a United States Citizen Yes A No [] tfno what is yourstatus: of Birth(city & state): (77% Aa, Mother's Maiden Name: Cue F 7 last Worked: Mad iY 3 Of? How many total years have you worked: 2] dia trabajado Numero de anos trabajados language do you speak? Check all that apply: English ay Spanish LI) Other: address and phone number of someone who will always be able to contact you: ef _S ds AN§a0 fe IE kG x { 7¥ Telephone: Cellular Telephone:_( f6 DBS CIIIF By: Client LJ Attorney of Other Case 2:23-cv-01251-BNW Document 18 Filed 10/04/24 Page 16 of 17 Torrell Johnson Social Security case Responsible AAttttoorrnneeyy: Law Brreiannce C D. .S Rhaophilrfoin ga ta $t 2$4149.06.28 9 Supervising Attorney MVK at $244.62 Paralegal: Enny Perez ata $t 1$41379 DATE: TIME: PLGL: DESCRIPTION: 27-Jul-23 0.2 EP receipt of IFP forms, review for IFP eligibility and review of letter from client 11-Aug-23 0.4 EP review and filing of complaint to review the final decision of the Commissioner 14-Aug-23 0.2 EP preparation of consent 19-Oct-23 0.2 EP preparation of letter to client with status 10-Oct-23 0.2 EP review of notice of appearance 10-Oct-23 0.9 EP receipt of transcript; OCR, preparation of memorandum to LDR regarding same 7-Dec-23 0.2 EP preparation of status report to client 28-Aug-24 0.1 EP receipt of judgment 28-Aug-24 0.1 EP receipt of memorandum and opinion Subtotals 2.50 $447.50 DATE: TIME: ATTY: DESCRIPTION: 7-Jul-23 0.9 BCS review of AC decision 7-Jul-23 0.5 MVK review of AC decision re DC appeal 10-Jul-23 0.5 BCS preparatoin of letter to client re: DC 28-Jul-23 0.1 MVK review of IFP 28-Jul-23 0.3 MVK review of complaint 10-Oct-23 0.1 BCS receipt and review of memorandum from EP re: memorandum 29-Oct-23 4.4 BCS beginning of opening brief Page 1 of 2 Case 2:23-cv-01251-BNW Document 18 Filed 10/04/24 Page 17 of 17 30-Oct-23 6.4 BCS continuation of Opening Brief 1-Nov-23 4.7 BCS completion 2-Nov-23 0.3 MVK review, edit and filing of brief 6-Dec-23 3.7 BCS review of counter motion and preparation of reply 7-Dec-23 0.5 MVK review, edit of reply 30-Aug-24 0.4 MVK review of decision 9-Sep-24 0.4 BCS review of decision 9-Sep-24 0.2 BCS preparation of letter to client regarding District Court 9-Sep-24 0.7 BCS prepartion of EAJA request Subtotals 24.1 447.5 $244.62 $5,895.34 TOTAL EAJA $6,342.84 Page 2 of 2