COMPLAINT FOR ADMINISTRATIVE REVIEW STATE OF ILLINOIS UNITED STATES OF AMERICA IN THE CIRCUIT COURT OF THE EIGHTEENTH JUDICIAL CIRCUIT 4026 (New. 02/08) COUNTY OF DU PAGE PLAINTIFF vs CASE NUMBER DEFENDANT COMPLAINT FOR ADMINISTRATIVE REVIEW File Stamp Here The Plaintiff states that: 1. The Plaintiff resides at 2. The Defendant's principal place of business is 3. A final administrative decision was rendered by the Defendant affecting the rights of the Plaintiff on . 4. The Plaintiff desires a judicial review of said decision, a copy of which is attached as Exhibit 1, because such decision is not in accordance with the law. 5. The Plaintiff has exhausted all available administrative remedies and has no further plain, speedy or adequate remedy in the ordinary course of law. 6. The Defendant is hereby requested to file an answer consisting of the record of the proceedings held before an administrative agency. Wherefore, the Plaintiff prays that said record be judicially reviewed. Under the penalties as provided by law pursuant to Section 735 ILCS 5/1-109 of the Code of Civil Procedure, the undersigned certifies that the statements set forth in this instrument are true and correct. Name: DuPage Attorney Number: Attorney for: Address: City/State/Zip: Telephone Number: PRO SE Signature of the Plaintiff Date CHRIS KACHIROUBAS, CLERK OF THE 18th JUDICIAL CIRCUIT COURT © WHEATON, ILLINOIS 60189-0707 American LegalNet, Inc. www.FormsWorkFlow.com