CLAIM FOR DAMAGE, INSTRUCTIONS: Please read carefully the instructions on the ORM APPROVED INJURY, OR DEATH —_ | hc em oretremeetewemecigae | He ‘dona netrctons 1. Submit To Appropriate Federal Agency: 2, Name, Adress of Salman and claimants personal representative, United States immigration and Customs Enforcement Headquarters Fajapoe neocons on rverse,) (Number Stoet, CH), Sie ond Ze ‘500 12h St SW, Washington, OC 20596 Arqumios Bautista (contact trough counsel dented below) Mark Siverston ‘Amarcan Chl Liberies Union Foundation of Colorado +400 Corona Soe, Denver, CO 80218 3. TYPE OF EMPLOYMENT | 4 DATE OF BIRTH | 5, MARITAL STATUS | 6, DATE AND DAY OF ACCIDENT 7. TIME (AM.OR PM) OMILTARY ocCMILIAN | aire/1000 Single ‘apa 2, 2010) Gam to 10am 8, Basis of Cai (State in deta the known facts and creumstances allending the damage, ejury, or death, Mentiying persons and propery vad, the place of occurence andthe cause therect. Use eddtonal pages f necessary) Please seo attached ® PROPERTY DAMAGE [NAME AND ADDRESS OF OWNER, IF OTHER THAN CLAIMANT (Number, Set Cy, Sale, and Zp Cac not appicable SEF. DESCRIBE TH PROPERTY, NATURE AND EXTENT OF OAVAGE AND THE LOCATION WHERE PROPERTY MAY BE MEPECTED {Gee instuctonsoneverse sae) RUS THE BASIS OF THE CLAM. IF OTHER THAN CLAIMANT, STATE NAME OF 1. ‘STATE NATURE AND EXTENT OF EACH INDURY OR CAUSE OF DEATH, WHC? ie Bautsta was subjoctod to an unusiie loss of bert for gavel hour, snd he wae ago subjected to an unjustifieg invasive and degrading search of his bovy. ‘ WITNESSES NAME ‘ADDRESS (Nurber, See, iy. Ste, nd Zp ose) [Pease soo attached Please see alached 12, (Geeinerucions on eveee) [AMOUNT OF CLAM in galirs ‘2a, PROPERTY DAMAGE "25 PERSONAL INAURY "25, WRONGFUL DEATH 12 TOTAL ature spcty may enine eet your ips) not applicable $200,000 ot appiabie $200,000 {CERTIFY THAT THE AMOUNT OF CLAIM COVERS ONLY DAMAGES AND MJURIES CAUSED BY THE INCIDENT AROVE AND AGREE TO ACCEPT SAID AMOUNT FULL SATISFACTION AND FINAL SETTLENENT OF THis CLalt ‘oe SEY OF CUB inom) Di Ravaiedmmnenwonm | WOE OFS [' a someone | Ypolp ‘Cv ENA ron ese Cmaps rox radbuven Ceara rete sea [FRAVOULENT CLA “Tie lanat aio the nes States Government orn ci pany ofrattess than | Fine, nptonment or ath (See BUS. 27, 10 38050 and notre than 610000, ps3 eae anu donages sores * ‘ > Sythe Goverment (Sow T1USC- 3725). ene TEN FSODOETTOAE STAND RRDFORITSS PRESCRISED BY DEPT, OF JUSTICE creaINSURANC: = COVERAGE Indore subrogee deer my be edicts eaten hat he cman rove he flotng nora agarg the newance covergo oh while o HES. | CLAIM SHALL BE DEEMED TO HAVE BEEN PRESENTED WHEN & FEDERAL ‘AGENCY RECEIVES FROMAGLAMANT.HISDULY AUTHORIZED AGENT. OR LEGAL REPRESENTATIVE, AN EXECUTED SIANDARD FORM! 88 OR OTFER WRITTEN [NOTIFICATION OF AN INGDDENT, ACCOMPANIED BY A CLAIM FOR NONEY ature to completely exacute tis form ort spl the requested materi within {woyeus em te dae th lam acerued may render your im ava. Acai ered een whens ech yt apropatago0, not When Hie iosructon's needesin comping thisform th agency ste ine onthe reverse ‘ide maybe caracled Compt epllons parang fo ime tented er he Federal Tor Caer het can be fou ie 28, Coda of Peer Requlaons, Pte, May sprcas hee ned xorg cpio row oe Sr ‘Tne lan maybe had bya duly vthoraed agent or te lga presence, rode ‘one sett tothe Governmental ecaating expense Sunray ost or te lamar Aca presen by on agar x ga rere nus be preseresin be nmecfine daira Ihe lamin signed by ha eget rapa (Goreseraive, must show the te or logseapacy of te personage an be ‘Seconparodby evtonce of ish cuorty to pase a caiman bole ne cat [Ss egertexaauoysamrisatr prom, pra or ther eer ctrartintondst efor bom patscoaty ans roped damage, ne seu foreach 15. Doyousery ecidetirawance? Yes yee, give name ard dies wsutnae company (Nurber, Sed, ly, Salo, a4 Zp Code) and pley number ONO not applicable “6: Have you tld alam on ournsuranoecarerin sane, andi, BAA overage ordeductie? Clves Bh not applicable 16: chim hasbeen fled wh yur carr, wha cson hs your ns taken or roped fake wth efeenca 0 your Cam? (tl cers ayo aan hee faa) ‘not applicable 1: Dayou cary pale Sabi and propery camegeinsrmcs? Yes Wye, genome and acres nsureos caer Number, Sst, Cy, Sale and Ze Code) NO Claims presented under the Federal Tort Claims Act should be submitted directly to the “appropriate Federal agency” whose 3(s) was involvedin the incident. Ifthe ineidentinvolves more than one claimant, each claimant should submita separate claim Complete all ioms - Insert the wore NONE where applicable. DAMAGES 1A SUM CERTAIN FOR NIURY TO OR LOSS OF PROPERTY, PERSONAL INUURY, O8 DEATH ALLEGED To HAVE OCGLIRRED BY REASON OF THE INCIDENT. ‘THE CLADIMUST BE PRESENTED TO THE APPAOPRATE FEDERAL AGENGY PITH. ‘THO YEARS AFTER THE CLA ACCRUES, ‘The amount clmed stould be sbsarted by copetel evidence a flows: (2) supper ot tein peeling dest, te csiman shuld ub writen sty eters ace, own iret ett i.e ean ‘Shortt vesevar th ogi a permanent aby, any, he pognons, tthe pelod {rosptaeaton, or capacaton aching Homzad lao asa, hap, or bral ‘ipenees ely weed 2 In supp of sins for darage to property wich ase o canbe economy sce, heart shoul utr tat vo Sead nod staat easy rls darned aoa, a Heras Dar ate, esemce sed cos (6) Insupprt feast damage opopaty which ot economia eat of “nsenaryeestordertoyed ha Semen sous ear sarc tse signa cot ‘ine propery. tne dee parce, apd te act he propery th befre sn ha Stade 51 stores shold bo by Saoesea compatrt parsers pet ‘pute delete or iis fama wth tye of prosry damaged ye er nae ‘Simpevetsdes. snd naive canted or bang st end coed (e) Faia to spcty a sum cota wl ender your lao Iva nd ay resin Tis Nats ie prods in aecrsane wn th Prise A, § US. $5209), and ‘ences the nfrmaten requected in that o wie the Neos atocnes "Aamo: a equi termasonsoicedpursuaae one erro feteinng S08 von Huse sth aes, USE HTT eg 18, Pca Purpose: The orate equesisate te utodin exiting sams C. Rauine Use Seo te Notoas of 8 tome of Recaro the gery loam you ‘Se utring sonnets trator ©. eto Fatur fo Respond Dieoere is veut. However. flue a sppy lt ort purpose the Papert Rescson At 44 US. 350, Pus reporting han friction iforatonis exile avrage Shoup spores ‘neluagine bef reenng nsuctonsercvng exsing Uta soues ging and atring he nea, oh colag senile cvecion nor Sod (veri repurgis bren eatmate or any ce pelo We calecton ftlaraoninduing suggestion ox reding hs bade, ft Det, Toe Sarah, Alc Papen Reston So Gs Buon operat of use, Was 2080 efoto raya od Boe Gone complae a) tere SF85 BACK8. Basis of claim Mr. Arquimides Bautista (“Claimant”) is a United States citizen. On April 2, 2010, he was subjected to violations of his constitutional right to be free of unreasonable search and seizure, as well as false arrest, false imprisonment, and battery, in violation of Nebraska tort law, by agents and employees of United States Immigrations and Customs Enforcement, an agency of the United States Department of Homeland Security. (On the day in question, Mr. Bautista was traveling with a group of 35-40 persons from the Denver, Colorado, area to attend an Amway convention in Omaha, Nebraska. The group traveled on a chartered bus owned by Global Transportation. Mr. Lawrence G, Newton drove the bus. The group was planning to stay at a Hilton Hotel in the Omaha area. ‘The bus arrived in the Omaha area early on the morning of April 2, The bus stopped at a MeDonald’s restaurant at 2410 Cuming Street in Omaha so that the passengers could get breakfast. Deportation Officer Linda Minze was at the restaurant when the passengers entered the restaurant. Linda Minze then set in motion a series of events that led to the tortious acts against Mr. Bautista and other passengers. The following facts appear in a report signed by Deportation Officer Ricardo Galindo: DO Minze observed approximately thirty people enter the restaurant and walk to the counter. All were speaking in the Spanish language. DO Minze is fluent in the Spanish language and overheard the group talking and heard statements that made DO Minze think that the group was passing through the area and had been traveling for awhile. Based upon her 19 years of experience as an Immigration Officer, the conversations in Spanish that she was hearing, and the dress of the individuals she suspected the group to a possible smuggling load. ‘The report provides no details to explain what Minze meant by “the dress of the individuals.” Based on Minze’s report, additional officers of ICE arrived at the McDonald’s restaurant. ICE. officers stationed vehicles at the front of the bus and at the back of the bus, thus requiring the movement of the ICE vehicles before the bus would be able to leave the restaurant parking lot. After the passengers returned from the restaurant and got back on the bus, Officer Galindo approached the bus and spoke with driver, Mr. Lawrence Newton. Mr. Newton explained that Amway had hired his company, Global Transportation, Inc., to drive the passengers from Denver to the downtown Hilton Hotel in Omaha for a convention, He said that me makes the trip approximately every three months to either Omaha or Kansas City. The conversation with Mr. Newton was obviously sufficient to dispel any remotely arguable basis for crediting Minze’s suspicion of a “smuggling load.”Nevertheless, despite the absence of any reasonable suspicion, ICE officers boarded the bus. ‘They identified themselves as ICE officers and began demanding that various passengers produce identification or other papers. ‘The ICE officers barked commands and demanded compliance. They ordered passengers to turn off their cell phones and threatened to confiscate them if passengers used the phones. ‘The passengers were not free to leave. Mr. Bautista was asked for his papers. He stated, accurately, that he is a citizen. He produced his wallet that contained his valid State of Colorado photo ID card. After demanding papers from a handful of passengers, the ICE agents decided to arrest all of the passengers, including Mr. Bautista. Without providing any explanation to the passengers, the ICE agents directed the bus driver to transport all the passengers to a Department of Homeland Secutity facility. On information and belief, this facility is located on Avenue H in Omaha. Upon arriving at the facility, Mr. Bautista was ordered to step down from the bus, He was ordered to empty his pockets. He was ordered to put his hands against a wall. An ICE officer puts his hands on Mr. Bautista and subjected him to a thorough pat-down body search. He was then confined in a cell. When he was removed from the cell, he was interrogated, fingerprinted, and photographed before being released. 11. Witnesses Name Address Linda Minze, Deportation Officer ICE, Omaha, Nebraska Ricardo Galindo, Deportation Officer ICE, Omaha, Nebraska Pat Burns, Deportation Officer ICE, Omaha, Nebraska SSA Dave Sullivan ICE, Omaha, Nebraska SSA Brent Morral ICE, Omaha, Nebraska Jason Francke, Deportation Officer ICE, Omaha, Nebraska Adam Minze, Deportation Officer ICE, Omaha, Nebraska Rob Green, Deportation Officer ICE, Omaha, Nebraska Greg Hammer, Deportation Officer ICE, Omaha, Nebraska Lawrence G. Newton [bus driver] 720 Bunting Drive, Lafayette, CO 80026 Rosalba Artimas (represented by undersigned counsel) Additional passengers on bus ICE has contact information for additional passenger/witnessesC. Ray Drew, Executive Director + Mark Silverstein, Legal Director Authorization for representation in administrative claim 1 authorize attomeys working with the American Civil Liberties Union Foundation of Colorado, including Mark Silverstein, Rebecca Wallace, and Hans Meyer, to represent me in pursuing an administrative claim to seek compensation for me from the United States for unlawful actions, in April, 2010, of employees of United States Immigrations and Customs Enforcement. Ag wick Bulls, 10 {tq \zo10 Arquimides Bautista Date State of Colorado) ) ss County of Denver) ‘The foregoing instrument was executed before me this 19" day of October, 2010 by Arquimides Bautista, Qn Qe Womda Notary DEBR, My Commission expires: istry one ® §- Ab — Do 14 State of Colorado 400 Corona Street * Denver, CO 80218-3915 + 303-777-5482 x114 + FAX 303-777-1773 * msliver2@attnet ACLU of Colorado... because liberty cannot protect itself