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: E-mail: Atty. Reg. #: Division 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 35 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: JDF 610 R7-12 COMPLAINT FOR JUDICIAL REVIEW PURSUANT §24-4-106, C.R.S. AND REQUEST FOR STAY AND DESIGNATION OF RECORD © 2012 Colorado Judicial Department for use in the Courts of Colorado Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 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.) 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 JDF 610 R7-12 COMPLAINT FOR JUDICIAL REVIEW PURSUANT §24-4-106, C.R.S. AND REQUEST FOR STAY AND DESIGNATION OF RECORD © 2012 Colorado Judicial Department for use in the Courts of Colorado Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com