1. JAN, 3 1 . 2 0 1 2 2:4?PM
FORM APPROVED
CLAIM FOR DAMAGE, INSTRUCTIONS: Please read carefully the instructions on the
0MB NO.
reverse side and supply infbnnation requested on both sides of tfiis
INJURY, OR DEATH form. Use addilional sheet(s) rf necessary. See rBverse side for
1105-0008
additional instructions.
1. Submit To Appropriate Federal Agency: 2. Name, Address of claimant and claimant's personal representative, if
any. (See instrucfions on reverse.) (Nunber, Street, City, State and Zip
HENNEPiN COUNTY HUMAN S E R V I C E S & P U B U C HEALTH DEPT. Code)
CHILD PROTECTION FIELD UNIT and GUARDIAN AO LITEM PROGRAM Michael David Nazario
590 Park Ave, Minneapolis MN 55415, Tel 612-348^824 Fax 612-348-4154 Joy Regina Nazario, spouse
PAREIvfTAL FEE UNIT, Healtti Services BIdg 9. L880,525 Portland Ave South
Minneapolis MN 55415-1569 Fax 612-348-0269 MinneapoRsMN 55418
3. T Y P E O F EMPLOYMENT 4. DATE O F BIRTH 5. MARITAL STATUS 6. DATE AND DAY O F ACCIDENT 7. TIME (A.M. OR P.M.)
• MILITARY KCIVILIAN Married January 20,2012 3:36 PM CST
8. Basis of aaim (Stale In detail the Imown facts and drcumstances attending the damage. Injury, or death, Wenttfying persons and property involved, the
place of occurrence and the cause thereof. Use additonal pages if necessary.) , , ^ ^ T , . J ,
Debbie M Sllvereteln/HSPS/Hennepin MSW, LICSW Supervisor, Child Protection Ffald did censor omtt and faisily case reports submitted to Chnstine Spaulding
and Karin Chedlater Hennepin County Attorney's Office ChUd Protection Division who committed Fraud Upon The Court by Entering Falsified Case Reports into
he Record of State of Minnesota 4th Judidal District Family Court Div. Case No. 27-JV-11 -7365 which resulted In Dlstria Court Judge Kathym Quaintance
llegaiiy transferring parental rights In violation of rights under color of law 18 U.S.C. S e c 242,18 U.S.C. S e c 245; 42 U.S.C. S e c 1963; hi violation of U.S.
Womey General's definition OJfidai ConrupHon Fraud Civil Rights; in violation of Minn Stat Sec 260C.001 subd. 2(b)(3); Sac 260C.007, subd. 6(2)0) sec
26OC.007 subd. 6(9), which caused Recovery Act FraiKl and Waste billing for concussion irijury sustained by Nazario's daughter in foster care, false arrest
jnlawful in^rtsonment of Protector Nazario Parents, children at highest risk of injury in St. Joe's Sheiter; Financial Crisis through payment of legal fees and bail.
9. • WtOPERTy DAMAGE
NAME AND ADDRESS OF OWNER, IF OTHER THAN CLAIMANT (Number, Street, CMy, State, and Zip Code).
BRIEFLY DESCRIBE THE PROPERS. NATURE AND EXTENT OF DAMAGE AND THE LOCATION WHERE PROPERTY MAY BE INSPECTED.
(See IruuucUorw on reverse aide.)
10. PERSONAL INJURY/WRONGFUL DEATH
STATE NATURE AND EXTENT OF EACH INJURY OR CAUSE OF DEATH. WHICH FORMS THE BASIS OF THE CLAIM. IF OTHER THAN CLAIMANT, STATE NAME OF
INJURED PERSON OR DECEDENT
Separation Trauma PTSD Parent Alienation Court Ordered Chad Abuse concussion received In a foster placement and DHS billed Federal Crime Victim
:;iaimant8 Michael and Joy Nazario after illegally transferring parental rights. Public iDe^maHon 01/20/12 false arrests unlawful imprisonment ongoing payment
]f attorney's / expert viritnessas fees forced case plan contracts of DHS threaten job toss of two professional financial services Industry U.S Economy career
»ntributors who have acted lawfully cooperated fully vnth law enforoerrwnt but a corrupt sodal worker continues to use a report of a 54 year old neighbor who
i a « s i n r p apnlnqbpri fnf maHnp tho falan rlnhti to mjt,r up thp rinig arth/Wy nf hprnrinH rhllrfn>n anrt IhPir fitenri* w/Hnp.«fiad hy Nazarln MMte^n
11. wrmEssES
NAME ADDRESS (Number, Street, CHy, State, and Zip Code)
Evidence Gathering IDeposiUon Expert Witness Roxanne Grtnage, Legal Administmlive Assistant
Testimony Claims Intake Assessment Docket Analysis HireLyncs Administrative Sendees
Exhibits Index Trial Prep Binder Witness Ust and U.S. Citizens Pubik: Docket Database
Legal Administrative Assistant VertficatkHi Forthcoming PO Box 22225. Phiiadetph'ia Pa 19136 Tel 267-444-0594 Fax 215-405-2939
Case Study Verified: http-7/hiralyrics.om/minnesotaftuniiiesnewdviIright8heroes.html
12. (Sa«ln»truclion»ontwer»e,) AMOUNT OF CLAM (in dollBiB)
12a. PROPERTY DAMAGE t2b. PERSONAL INJURY 12c WRONGFUL DEATH 12d. TOTAL (Failure ki specify may caiwe
fbcteiture <tf your right*.)
$3,000,000.00 $3,000,000.00
I CERTIFY THAT THE AMOUNT OF CLAIM COVERS ONLY DAMAGES AND INJURIES CAUSED BY THE IHCIDEMT ABOVE AND AGREE TO ACCEPT SAID AMOUNT IN
FULL SATISFACTION AND FINAL SETTLEMENT OF THIS CLAIM
13a. SISNATLiRE OF CIJAIANt (See InatiudlonB on reverse akia.) 13b. Phone number of person signing fonn 14. DATE OF SIGNATURE
January 31,2012
cnm. PENALTY FOR PRESENTING CRIMINAL PENALTY FOR PRESENTING FRAUDULENT
FRAUDULENT CLAM CLAM OR MAKING FALSE STATEMENTS
The dalmant Is Ilablatothe United Stales Governmenttarthe civil penalty of not test than Fine. Imprteonmenl, or lioth. (See IB U.S.C. 287,1001.)
(5,000 and not more than $10,000, plus 3 times (he an^ount of damages sustaiiwd
by the Government (See 31 U.S.C. 3729.)
95-109 NSN r64a-0l)-634-«l46 STANDARD FORM 95
PRESCRIBED BY DEPT. OF JUSTICE
29 CFR 14.2.