CHRIS KACHIROUBAS, CLERK OF THE 18th JUDICIAL CIRCUIT COURT251 WHEATON, ILLINOIS 60187-0707 UNITED STATES OF AMERICA STATE OF ILLINOIS COUNTY OF DU PAGE PLAINTIFF-VS-PRO SE COMPLAINT FOR ADMINISTRATIVE REVIEW Now comes the Plaintiff (Pro-se) ,and complains that the Defendants: Illinois Department of Employment Security: Director of the Illinois Department of Security, Illinois Department of Employment Security: Board of Review, both administrative agencies of the State of Illinois, and (employer) and alleges as follows: *Name:Address:Telephone: ( )File Stamp Here, a final administrative decision was rendered by the Department ofPlaintiff resides in DuPage County, Illinois.OnEmployment Security; Board of Review, affecting the rights of the Plaintiff.(MONTH DAY YEAR)The Plaintiff desires a judicial review of said decision, a copy of which is attached hereto as Exhibit 1, because such decision is not in accordance with the law. was a party of record in the administrative proceedings sought to be reviewedOn in this action.(EMPLOYER)Department of Employment Security: Board of Review is hereby requested to file an answer consisting of the record of proceedings had before the said administrative agency.The Plaintiff has exhausted all available administrative remedies under the Act and has no further plain, speedy and adequate remedy in the ordinary course of the law.WHEREFORE, The Plaintiff prays that said record be judicially reviewed. Under the penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, the undersigned certifies that the statements set forth in this instrument are true and correct Signature of the Pro-se Plaintiff Date:1.2.3.4.5.6.(* This action is pursuant to 735 ILCS 5/3-101 through 735 ILCS 5/3-112 inclusive) CASE NUMBER employer,DEFENDANTDIRECTOR OF ILLINOIS DEPARTMENT OF EMPLOYMENT SECURITY: BOARD OF REVIEW, an administrative agency in the State of IllinoisILLINOIS DEPARTMENT OF EMPLOYMENT SECURITY, an administrative agency in the State of Illinois;ADMINISTRATIVE REVIEW-EMPLOYMENT - PRO SE COMPLAINT3135 (Rev 11/18) IN THE CIRCUIT COURT OF THE EIGHTEENTH JUDICIAL CIRCUIT Email: American LegalNet, Inc. www.FormsWorkFlow.com