(Rev. 9/6/00) CCL 0093 IN THE CIRCUIT COURT OF COOK COUNTY , ILLINOIS ________________________________________________ PLAINTIFF vs. ILLINOIS DEPARTMENT OF EMPLOYMENT SECURITY an administrative agency in the State of Illinois; DIRECTOR OF ILLINOIS DEPARTMENT OF EMPLOYMENT SECURITY: BOARD OF REVIEW, and administrative agency in the State of Illinois: NO. ____________________________ ________________________________________ employer, DEFENDANTS PRO SE COMPLAINT FOR ADMINISTRATIVE REVIEW Now comes the Plaintiff ____________________________________________________________ pursuant to Chapter 735 ILCS 5/3-101 through 735 ILCS 5/3-112 inclusive and complains of the Defendants, ILLINOIS DEPARTMENT OF EMPLOYMENT SECURITY: DIRECTOR OF THE ILLINOIS DEPARTMENT OF EMPLOYMENT SECURITY; BOARD OF REVIEW, administrative agencies of the State of Illinois: __________________________________________________________________ (employer) and alleges as follows: 1. Plaintiff resides in Cook County, Illinois. 2. On ________________________________, a final administrative decision was rendered by the Department of Employment Security; Board of Review, affecting the rights of the Plaintiff. 3. The Plaintiff desires a judicial review of said decision, a copy of which is attached hereto as Exhibit No. 1, because said decision is not in accordance with the law. 4. _____________________________________________ (employer) was a party of record in the administrative proceedings sought to be reviewed in the action. 5. 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. 6. 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. Atty. No.:__________________ Name: ________________________________________________ ____________________________________________ Plaintiff Pro Se Atty. for: ____________________________________________ Address: ____________________________________________ City/State/Zip: ________________________________________ Telephone: __________________________________________ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Print This Form For your protection and privacy, please press the Clear This Form button after you have printed the form. Clear This Form