District Court ______________________ County, Colorado Court Address: Plaintiff: ________________________________________ v. Defendant: _________________________________ (Name of Agency) Attorney or Party Without Attorney (Name and Address): COURT USE ONLY Case Number: Phone Number: FAX Number: Division E-mail: Atty. Reg. #: Courtroom COMPLAINT FOR JUDICIAL REVIEW PURSUANT TO §24-4-106, C.R.S. AND REQUEST FOR STAY AND DESIGNATION OF RECORD I, __________________________________ (name of Plaintiff) request this Court to commence an action for judicial review issued by ______________________________ (name of agency) on __________________ (date) pursuant to §24-4-106, C.R.S. I presently reside in _____________________ (name of county) Colorado and this Complaint has been timely filed as it is within 30 days after the agency action became effective. A. The following facts show how I have been adversely affected or aggrieved: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ B. The reasons entitling me to relief are as follows: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ C. The relief that I request is as follows: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ I request an immediate stay of the agency action on the grounds that said action has caused irreparable injury as follows: (Please identify each issue separately and if you need more space than is provided, attach additional pages to the form.) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ JDF 610 11/07 COMPLAINT FOR JUDICIAL REVIEW PURSUANT TO §24-4-106, C.R.S. Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com I designate the following documents as relevant parts of such record, pursuant to §24-4-106(6), C.R.S. 1. The original or certified copies of all pleadings, applications, evidence, exhibits, and other papers presented to or considered by the agency. 2. A complete transcript of the hearing held on _____________________ (date) at _________ (time) by the agency identified in this action. 3. The written order issued by the agency identified in this action. I, hereby request that this Court find that the hearing officer’s decision be reversed. _________________________________________ Signature of Attorney for Plaintiff Date ___________________________________________ Signature of Plaintiff Date ____________________________________________ Printed Name of Plaintiff ____________________________________________ Address __________________________________________ City, State, Zip Code __________________________________________ Area Code) Telephone Number Certificate of Service I hereby certify that on ______________________ (date) a copy of this Complaint by first-class certified mail to the following: Colorado Attorney General 1525 Sherman Street Denver, Co 80203 ______________________ (name of agency) ______________________ (address) ______________________ (city/state/zip code) Other: _________________ _____________________________________ Signature of Person Mailing Documents JDF 610 11/07 COMPLAINT FOR JUDICIAL REVIEW PURSUANT TO §24-4-106, C.R.S. Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com