Case 8:24-cv-00029-TJM-DJS Document 1 Filed 01/08/24 Page 1 ofU.S.
12
DISTRICT COURT – N.D. OF N.Y.
FILED
UNITED STATES DISTRICT COURT FOR THE Jan 08 - 2024
NORTHERN DISTRICT OF NEW YORK
PLATTSBURGH DIVISION John M. Domurad, Clerk
COTT PHILLIP LEWIS,
S
§
Plaintiff, §
§
v. § Jury Trial Demanded
§ 8:24-cv-29 (TJM/DJS)
itizens United, Inc.
C §
Defendant. §
§
PLAINTIFF’S ORIGINAL COMPLAINT
NOW COMES PLAINTIFF, Scott Phillip Lewis, and files Plaintiff’s Original Complaint.
Plaintiff files this Americans with Disabilities Act and Rehabilitation Act lawsuit for cause of
action will show the following:
I. PARTIES
1. Plaintiff is Scott Phillip Lewis (“Plaintiff”), an individual and citizen of the United States of
America.
2. Defendant is Citizen Advocates, Inc. (“Defendant”) is a not-for-profit 501(c)(3) organization
located in Essex County, New York and can be served through its Director, Joe Riccio, at 324
Creighton Road, Malone, NY. Service is requested contemporaneously with the filing of the
complaint.
II. VENUE AND JURISDICTION
3. The court has jurisdiction over this lawsuit according to 28 U.S.C§1331. The court has
personal jurisdiction because the American with Disabilities Act of 1990 and Rehabilitation
Act of 1973 are laws of the United States.
4. Venue is proper in the Plattsburgh Division of the United States District Court for the
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Case 8:24-cv-00029-TJM-DJS Document 1 Filed 01/08/24 Page 2 of 12
Northern District of New York, under 28 U.S.C§1391(b). Citizen Advocates, Inc. is
situated in this district and a substantial part of the events or omissions giving rise to claims
in this lawsuit occurred within this judicial district.
III. FACTUAL ALLEGATIONS
A. Plaintiff’s Relevant Medical History
5. Plaintiff’s relationship with chronic pain begins in 2012. At this time, Plaintiff had their left
wrist severely broken, requiring a fixation with screws and plates used to piece the arm back
together. Surgery was performed at Upstate Orthopedics in East Syracuse, New York. After
surgery, Plaintiff was prescribed Oxycontin, a pain killer known for its high risk for addiction
and dependence. Oxycontin was originally advertised as not being addictive by distributors
such as Purdue Pharmaceuticals located in Stamford, Connecticut.
6. The Johns Hopkins Medicine website explains “[w]hen pain becomes such a problem that it
interferes with your life's work and normal activities, you may become the victim of a
vicious circle. Pain may cause you to become preoccupied with the pain, depressed, and
irritable. Depression and irritability often leads to insomnia and weariness, leading to more
irritability, depression, and pain.”
https://www.hopkinsmedicine.org/health/conditions-and-diseases/chron
ic-pain#:~:text=Pain%20may%20cause%20you%20to,suffering%2C%20sleeplessness%2C
%20a nd%20sadness).
7. By 2013, Plaintiff had noticed changes in life’s work and normal activities because of the
constant chronic pain in the left wrist. By May 2014, Plaintiff made the choice to remain
abstinent from alcoholic beverages as the chronic pain mixed with alcohol had become an
unpleasant experience with irritable behavior becoming more frequent. Shortly after making
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Case 8:24-cv-00029-TJM-DJS Document 1 Filed 01/08/24 Page 3 of 12
this choice, Plaintiff was hired as a Derivatives Trading Specialist at optionsXpress by
Charles Schwab and JV Lacrosse Coach at Vandegrift High School in Austin, TX. Plaintiff
moved from Syracuse, New York.
8. In November 2015, Plaintiff was involved in a hit and run accident on Rainey Street in
Austin, Texas leaving Plaintiff with a concussion and traumatic brain injury (TBI). The
police who were involved never followed up with Plaintiff, seemingly attempting to cover up
what happened. Plaintiff is still working on obtaining a full police report and information
from the officers involved at the November 2015 accident and cover up.
9. After the 2015 hit and run incident, Plaintiff experienced a progressive increase in
attention-deficit/hyperactivity disorder (“ADHD”) symptoms associated with the
post-traumatic stress disorder (“PTSD”) from the accident and lack of police professionalism,
follow up and transparency.
10.After the progression of symptoms of PTSD and ADHD from the 2015 hit and run accident,
Plaintiff had developed an alcohol abuse disorder over time. While some could see the
alcohol abuse, the root cause of the symptom went undiagnosed for a very long time. Even
though Plaintiff understood the symptoms he was experiencing, Plaintiff was bombarded
with conflicting opinions by individuals who did not care about the full truth, but instead
focused on selective facts that best fit a desired narrative and bias.
11.Again symptoms of PTSD and ADHD were further exacerbated on or around July 2018
when a former roommate and also a coach at Vandegrift Lacrosse Club told Plaintiff he had
paid money to have a man killed over a disagreement in a lacrosse game. Stunned by such
evil, Plaintiff experienced an even further increase in ADHD and PTSD symptoms and
separately, an increase in alcohol abuse, which is a symptom of PTSD and ADHD.
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Case 8:24-cv-00029-TJM-DJS Document 1 Filed 01/08/24 Page 4 of 12
12.Plaintiff made the choice to go to “A Forever Recovery,” a rehabilitation facility in Battle
Creek, Michigan. Plaintiff knew this was not a good fit, almost immediately, as the facility
wanted to focus solely on the alcohol abuse and not the reasons that caused such a symptom.
Plaintiff felt as if they were at a cult and made the decision to leave after approximately
twelve (12) days. This experience affected Plaintiff’s overall well-being. “A Forever
Recovery” is now believed to be permanently closed.
13.As previously mentioned on January 25, 2019, Plaintiff was arrested for driving while
intoxicated in Williamson County, TX and had his left shoulder broken within the
Williamson County Jail.
14.The criminal charges associated with Plaintiff’s driving while intoxicated arrest were
dismissed for insufficient evidence on or around April 25, 2022. The civil lawsuit initiated
by Plaintiff against Williamson County, Texas is an active case in the United States District
Court for the Western District of Texas. The active litigation’s case number in the Western
District of Texas is 1:21-cv-00074.
B. Plaintiff’s Medical History with Citizens Advocates, Inc.
15.According to their website, “Citizen Advocates provides developmental disability, mental
health and substance abuse prevention, treatment and recovery services throughout Franklin,
Clinton, Essex, Hamilton and St. Lawrence counties” (https://citizenadvocates.net/about-us/).
16.On or around October 22, 2021, while receiving counseling through Better Help, an online
therapy platform, Plaintiff seeked an official diagnosis of symptoms of post traumatic stress
disorder (“PTSD”) and attention deficit/hyperactivity disorder (“ADHD”) that had continued
to progressively intensify and learn of options and resources available.
17.Plaintiff received an initial evaluation for intake online on or around October 22, 2021,
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Case 8:24-cv-00029-TJM-DJS Document 1 Filed 01/08/24 Page 5 of 12
performed by Joanna Politi, LMHC. The initial evaluation form is not signed (Exhibit A).
18.Even though a licensed medical health counselor is not licensed to make diagnosis’, Plaintiff
was nonetheless diagnosed by Joanna Politi for attention-deficit/hyperactivity disorder, and
nothing else (Exhibit B). Plaintiff’s post-traumatic stress disorder symptoms remained.
19.Plaintiff was unaware that his mother was given ROI status on October 22, 2021 (Exhibit C).
Joanna Politi states “verbal ROI” was given. Plaintiff did not intend to give unrestricted
access of his medical charts to his mother, Debbie Lewis, maiden name Stepien.
20.On or around October 26, 2021, Plaintiff had a second telehealth appointment with Joanna
Politi. The notes include a diagnosis of alcohol use disorder and/or alcohol dependency
(Exhibit D). This evaluation is also not signed.
21.Plaintiff was abstinent from alcohol for four (4) months, last having an alcoholic beverage on
or around June 12, 2021.
22.In other words, Plaintiff was diagnosed by someone not licensed to make diagnosis’ for
alcohol use disorder and alcohol dependence even though they had not had alcohol in four
(4) months.
23.Post-traumatic stress disorder or PTSD was completely ignored.
24.Plaintiff was unaware of the alcohol use disorder diagnosis at the time.
25.On or around January 10, 2022, Plaintiff had an initial psychiatric evaluation with John
Gomez, NP. His evaluation is unsigned (Exhibit E).
26.The evaluation form from January 10, 2022 shows a diagnosis and case formulation of
ADHD and alcohol use disorder, even though Plaintiff had not had an alcoholic beverage in
six (6) months now. Again, the symptoms of PTSD were ignored completely (Exhibit F).
27.The evaluation curiously includes a note requiring nursing supervision, stating “Patient
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Case 8:24-cv-00029-TJM-DJS Document 1 Filed 01/08/24 Page 6 of 12
requires nursing supervision to include; injections, Medication checks, and overall
monitoring of symptoms related to their primary diagnosis. Frequency determined by
nursing staff” (Exhibit G) This is utterly erroneous.
28.The bizarre sequence of ignoring Plaintiff’s PTSD symptoms and creating a diagnosis of
alcohol use disorder, when Plaintiff wasn’t using alcohol, culminated with a prescription of
adderall for ADHD and aripiprazole, which was sold to Plaintiff as an anti-anxiety
medication (Exhibit H).
29.Upon receiving the prescription, Plaintiff learned aripiprazole was a medicine used for autism
and/or schizophrenia, and Plaintiff was misled about the use of aripiprazole by John Gomez.
Plaintiff never took this medicine and confronted nurse practitioner in psychiatry John
Gomez upon learning of the purpose of aripiprazole.
30.The practice of using misrepresentations to trick patients into taking prescriptions is designed
to benefit only those prescribing the drugs. The practice of ignoring the root causes of
mental health symptoms and creating false diagnosis’ in order to justify prescribing pills
creates questions surrounding the motivation behind such behavior.
31.Plaintiff was prescribed pills for autism and/or schizophrenia but was told it was an
anti-anxiety medicine. Plaintiff was diagnosed with alcohol dependence even though he was
abstinent from alcohol for four (4) months. The symptoms of post-traumatic stress disorder
remained ignored.
32.Plaintiff’s trust was broken with the organization. Plaintiff seeked alternative treatment
providers.
33.Plaintiff was diagnosed with PTSD on or around May 3, 2023 (Exhibit I).
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Case 8:24-cv-00029-TJM-DJS Document 1 Filed 01/08/24 Page 7 of 12
IV. CLAIMS
Claim I - Violation of Title III, Americans with Disabilities Act of 1990
34.Plaintiff hereby incorporates all preceding paragraphs as if fully stated herein and alleges as
follows.
35."To state a claim under Title III [of the Americans with Disabilities Act ("ADA" or "the
Act")], [a plaintiff] must allege (1) that he is disabled within the meaning of the ADA; (2)
that defendants own, lease, or operate a place of public accommodation; and (3) that
defendants discriminated against her by denying her a full and equal opportunity to enjoy the
services defendants provide."Camarillo v. Carrols Corp., 518 F.3d 153, 156 (2d Cir. 2008).
36.Title III of the Americans with Disabilities Act of 1990 (“ADA”) prohibits discrimination on
the basis of disability in the activities of places of public accommodations and is codified
through 42 U.S.C § 12182(a) which states in full:
“ No individual shall be discriminated against on the basis
ofdisabilityin the full and equal enjoyment of the goods,
services, facilities, privileges, advantages, or
accommodations of any place of public accommodation by
any person who owns, leases (or leases to), or operates a
place of public accommodation.”
37.On or around February 2022, Citizen Advocate, Inc. received a $4,000,000 grant from the
Department of Health and Human Services.
38.The Press-Republican reported that “[t]hrough the initiative, Citizen Advocates implemented
a 24/7 Crisis and Recovery Center for the delivery of urgent care to treat mental health and
addiction, and launched a broad range of care coordination programs in conjunction with
other health care organizations, public safety and veterans groups”
https://www.pressrepublican.com/news/local_news/citizen-advocates-awarded-4-million-gra
nt/article_6364aa62-09be-575d-8fca-97ddf7148ad6.html.
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Case 8:24-cv-00029-TJM-DJS Document 1 Filed 01/08/24 Page 8 of 12
39.ADHD and PTSD are disabilities under the ADA.
40.The act is designed to prevent practices such as those described here within and performed
by Defendant.
41.Citizen Advocates, Inc. leases, owns or operates properties designed to provide healthcare as
a place of public accommodation in Malone, New York.
42.Defendant attempted to trick Plaintiff into taking a prescription that did not fit any diagnosis.
The sinister attempts to trick Plaintiff were performed because Plaintiff had a history of
ADHD, PTSD and alcohol abuse.
43. Defendant believed they could take advantage of Plaintiff.
44.Plaintiff’s symptoms of post-traumatic stress disorder intensified. Plaintiffs had the courage
to confront reality and be transparent about what they were dealing with, but were then
prescribed a pill for something they weren’t diagnosed with.
45.Plaintiff felt abandoned and not listened to by Citizen Advocates, Inc., exacerbating
symptoms of ADHD and PTSD.
46.Plaintiff had legitimate fears for his safety.
47.Plaintiff was denied full access to goods and services because of a disability. Instead,
Plaintiff’s disability was used to prescribe medicine which was unnecessary further injuring
Plaintiff.
48.Plaintiff was denied full access to goods and services when he was diagnosed by someone
who is not licensed to diagnose mental health conditions on October 25, 2021 by Joanna
Politi. Defendant perceived that Plaintiff could be taken advantage of and that his disability
would prevent the ability in taking any legal recourse.
49.Of course this assumption is flatly incorrect as 42 U.S.C § 12101(1) states:
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Case 8:24-cv-00029-TJM-DJS Document 1 Filed 01/08/24 Page 9 of 12
“ [t]he Congress finds that physical or mental disabilities in no way
diminish a person’s right to fully participate in all aspects of
society, yet many people with physical or mental disabilities have
been precluded from doing so because of discrimination; others
who have a record of adisabilityor are regarded as having a
disabilityalso have been subjected to discrimination.”
50.By trying to take advantage of Plaintiff’s disability to prescribe pills that are not necessary,
Defendant violated the ADA.
51.One reason for violating the ADA would be financial benefits to Defendant, such as
kickbacks, at the expense of Plaintiff’s or other patients overall health and disability.
52.Aripiprazole is also known as Abilify.
53.Upon information and belief, the drug makers of Abilify or aripiprazole faulted by properly
testing Abilify, aggrandized the benefits of Abilify, and encouraged physicians to use the
medication for purposes not approved by the Food and Drug Administration..
54.Plaintiff was injured because of distress over an improper diagnosis and improper
prescription. Again, Plaintiff had symptoms of PTSD which were ignored, while Plaintiff
was instead given a pill for nothing he was diagnosed with. This distress further injured
Plaintiff and was caused by Defendant’s ADA violations.
55.As a result of Defendant’s ADA violation, Plaintiff was angry and frustrated and experienced
an increase in PTSD symptoms, including but not limited to paranoia, distrust of others,
irritability, difficulty maintaining relationships, an inability to relax, the inability to care for
oneself, inability to work consistently, inability to focus, and inability to learn.
56.Plaintiff suffered emotional distress and worsening symptoms of ADHD and PTSD due to
Defendant’s ADA violations.
57.Plaintiff requests all relief and damages he may be entitled.
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Case 8:24-cv-00029-TJM-DJS Document 1 Filed 01/08/24 Page 10 of 12
Claim II - Violation of Section 504 of the Rehabilitation Act
58.Plaintiff hereby incorporates all preceding paragraphs as if fully stated herein and alleges as
follows.
59.Upon information and belief, Citizen Advocates, Inc. received Federal financial assistance in
2022, in the amounts of $4,146,750.
60.Under Section 504 of the Rehabilitation Act, individuals with disabilities are defined as
persons with a physical or mental impairment which substantially limits one or more major
life activities. A recipient of Federal financial assistance may not, on the basis of disability,
deny qualified individuals the opportunity to participate in or benefit from federally funded
programs, services, or other benefits or deny access to programs, services, benefits or
opportunities to participate as a result of physical barriers
(https://www.hhs.gov/sites/default/files/ocr/civilrights/resources/factsheets/504.pdf).
61.ADHD and PTSD are disabilities that create mental impairments that substantially limit one
or more life activities.
62.Plaintiff exhibited the inability to care for oneself, work consistently, perform manual tasks,
focus and learn.
63.Plaintiff did not receive the benefits of the federally funded programs and services.
64.In fact, Plaintiff was diagnosed by someone who is not licensed to make a diagnosis.
65.Citizen Advocates, Inc. allowed access to aripiprazole, a prescription that was not necessary
and instead rather dangerous to Plaintiff but denied Plaintiff access to the full array of
benefits that were provided.
66.Plaintiff was denied access to programs because of their disability.
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Case 8:24-cv-00029-TJM-DJS Document 1 Filed 01/08/24 Page 11 of 12
67.Defendant believed Plaintiff could be tricked into taking a prescription that was not
necessary.
68.Plaintiff was denied access to programs, services, benefits or opportunities as a result of a
discrimination due to disability.
69.By denying Plaintiff access to federally funded programs due to Plaintiff’s disability,
Defendant violated Section 504 of the Rehabilitation Act of 1973.
70.Defendant used Plaintiff’s disability to make decisions that were financially beneficial to
Defendant while denying the proper care and full benefits of Citizen Advocates, Inc. that
Plaintiff seeked.
71.Plaintiff requests all relief and damages he may be entitled.
V. DAMAGES
1. Plaintiff suffered and claims the following damages::
I. Actual Damages
● Past and future mental anguish
● Past and future impairment
● Past and future medical expenses
● Past and future loss of earning capacity
● Past and future physical suffering
VI. JURY DEMAND
72. Plaintiff respectfully requests jury trial pursuant to FED. R. CIV. P. 48.
VII. PRAYER FOR RELIEF
73. Accordingly, Plaintiff requests that judgment be awarded against Citizen Advocates, Inc. for:
(1)Compensatory damages;
(2)Punitive or exemplary damages;
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Case 8:24-cv-00029-TJM-DJS Document 1 Filed 01/08/24 Page 12 of 12
(3)Costs of Court;
(4)Prejudgment and postjudgment interest at the highest rate allowable under law;
(5)Unliquidated damages at the highest amount that is within the jurisdictional limits of the
court;
(6)And all over relief to which Plaintiff is justly entitled.
Respectfully submitted,
/s/Scott Phillip Lewis
Scott Phillip Lewis
1936 Saranac Ave. #3, PMB 411
Lake Placid, NY 12946
518-551-3061
scottphilliplewis@gmail.com
12
8:24-cv-29
JS 44 (Rev. 10/20) CIVIL COVER
Case 8:24-cv-00029-TJM-DJS DocumentSHEET
1-1 Filed 01/08/24 Page 1 of 1
The JS 44 civil cover sheet and the information contained herein neither replace nor supplement the filing and service of pleadings or other papers as required by law, except as
provided by local rules of court. This form, approved by the Judicial Conference of the United States in September 1974, is required for the use of the Clerk of Court for the
purpose of initiating the civil docket sheet. (SEE INSTRUCTIONS ON NEXT PAGE OF THIS FORM.)
I. (a) PLAINTIFFS DEFENDANTS
Scott Phillip Lewis Citizen Advocates, Inc.
(b) County of Residence of First Listed Plaintiff Essex County of Residence of First Listed Defendant
(EXCEPT IN U.S. PLAINTIFF CASES) (IN U.S. PLAINTIFF CASES ONLY)
NOTE: IN LAND CONDEMNATION CASES, USE THE LOCATION OF
THE TRACT OF LAND INVOLVED.
(c) Attorneys (Firm Name, Address, and Telephone Number) Attorneys (If Known)
II. BASIS OF JURISDICTION (Place an “X” in One Box Only) III. CITIZENSHIP OF PRINCIPAL PARTIES (Place an “X” in One Box for Plaintiff
(For Diversity Cases Only) and One Box for Defendant)
✖ 1 U.S. Government 3 Federal Question PTF DEF PTF DEF
Plaintiff (U.S. Government Not a Party) Citizen of This State ✖ 1 1 Incorporated or Principal Place 4 4
of Business In This State
2 U.S. Government 4 Diversity Citizen of Another State 2 2 Incorporated and Principal Place 5 5
Defendant (Indicate Citizenship of Parties in Item III) of Business In Another State
Citizen or Subject of a 3 3 Foreign Nation 6 6
Foreign Country
IV. NATURE OF SUIT (Place an “X” in One Box Only) Click here for: Nature of Suit Code Descriptions.
CONTRACT TORTS FORFEITURE/PENALTY BANKRUPTCY OTHER STATUTES
110 Insurance PERSONAL INJURY PERSONAL INJURY 625 Drug Related Seizure 422 Appeal 28 USC 158 375 False Claims Act
120 Marine 310 Airplane 365 Personal Injury - of Property 21 USC 881 423 Withdrawal 376 Qui Tam (31 USC
130 Miller Act 315 Airplane Product Product Liability 690 Other 28 USC 157 3729(a))
140 Negotiable Instrument Liability 367 Health Care/ 400 State Reapportionment
150 Recovery of Overpayment 320 Assault, Libel & Pharmaceutical PROPERTY RIGHTS 410 Antitrust
& Enforcement of Judgment Slander Personal Injury 820 Copyrights 430 Banks and Banking
151 Medicare Act 330 Federal Employers’ Product Liability 830 Patent 450 Commerce
152 Recovery of Defaulted Liability 368 Asbestos Personal 835 Patent - Abbreviated 460 Deportation
Student Loans 340 Marine Injury Product New Drug Application 470 Racketeer Influenced and
(Excludes Veterans) 345 Marine Product Liability 840 Trademark Corrupt Organizations
153 Recovery of Overpayment Liability PERSONAL PROPERTY LABOR 880 Defend Trade Secrets 480 Consumer Credit
of Veteran’s Benefits 350 Motor Vehicle 370 Other Fraud 710 Fair Labor Standards Act of 2016 (15 USC 1681 or 1692)
160 Stockholders’ Suits 355 Motor Vehicle 371 Truth in Lending Act 485 Telephone Consumer
190 Other Contract Product Liability 380 Other Personal 720 Labor/Management SOCIAL SECURITY Protection Act
195 Contract Product Liability 360 Other Personal Property Damage Relations 861 HIA (1395ff) 490 Cable/Sat TV
196 Franchise Injury 385 Property Damage 740 Railway Labor Act 862 Black Lung (923) 850 Securities/Commodities/
362 Personal Injury - Product Liability 751 Family and Medical 863 DIWC/DIWW (405(g)) Exchange
Medical Malpractice Leave Act 864 SSID Title XVI 890 Other Statutory Actions
REAL PROPERTY CIVIL RIGHTS PRISONER PETITIONS 790 Other Labor Litigation 865 RSI (405(g)) 891 Agricultural Acts
210 Land Condemnation 440 Other Civil Rights Habeas Corpus: 791 Employee Retirement 893 Environmental Matters
220 Foreclosure 441 Voting 463 Alien Detainee Income Security Act FEDERAL TAX SUITS 895 Freedom of Information
230 Rent Lease & Ejectment 442 Employment 510 Motions to Vacate 870 Taxes (U.S. Plaintiff Act
240 Torts to Land 443 Housing/ Sentence or Defendant) 896 Arbitration
245 Tort Product Liability Accommodations 530 General 871 IRS—Third Party 899 Administrative Procedure
290 All Other Real Property 445 Amer. w/Disabilities - 535 Death Penalty IMMIGRATION 26 USC 7609 Act/Review or Appeal of
Employment Other: 462 Naturalization Application Agency Decision
446 Amer. w/Disabilities - 540 Mandamus & Other 465 Other Immigration 950 Constitutionality of
Other 550 Civil Rights Actions State Statutes
448 Education 555 Prison Condition
560 Civil Detainee -
Conditions of
Confinement
V. ORIGIN (Place an “X” in One Box Only)
✖ 1 Original 2 Removed from 3 Remanded from 4 Reinstated or 5 Transferred from 6 Multidistrict 8 Multidistrict
Proceeding State Court Appellate Court Reopened Another District Litigation - Litigation -
(specify) Transfer Direct File
Cite the U.S. Civil Statute under which you are filing (Do not cite jurisdictional statutes unless diversity):
42 U.S.C § 12182; Americans with Disabilities Act; Rehabilitation Act
VI. CAUSE OF ACTION Brief description of cause:
VII. REQUESTED IN CHECK IF THIS IS A CLASS ACTION DEMAND $ CHECK YES only if demanded in complaint:
COMPLAINT: UNDER RULE 23, F.R.Cv.P. JURY DEMAND: ✖ Yes No
VIII. RELATED CASE(S)
(See instructions):
IF ANY JUDGE DOCKET NUMBER
DATE SIGNATURE OF ATTORNEY OF RECORD
FOR OFFICE USE ONLY
RECEIPT # AMOUNT APPLYING IFP Yes JUDGE TJM MAG. JUDGE DJS
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