Commonwealth of Massachusetts The Trial Court Probate and Family Court Department Division Docket No. Complaint for Judicial Review Pursuant to G.L. c.119A, §17 , Plaintiff V. Department of Revenue, Child Support Enforcement Division, on behalf of , Defendant 1. Now comes the plaintiff in the above entitled action seeking judicial review of an administrative decision of the Department of Revenue, Child Support Enforcement Division, under the provision of Chapter 119A, § 17. 2. Plaintiff resides at (Street Address) (City/Town) (State) (Zip) 3. Defendant is the duly authorized child support enforcement agency within the Commonwealth designated under Chapter 119A of the General Laws pursuant to Title IV Part D of the Social Security Act and has its principal place of business at 100 Cambridge Street, P.O. Box 9561, Boston, Massachusetts 02114. 4. Plaintiff is aggrieved by the defendant's final determination regarding actions taken in collecting and disbursing child support or, regarding the plaintiff's failure to comply with a subpoena, summons, or warrant/capias. The defendant's final determination was issued on . A copy of that final determination is attached. (Date) 5. Plaintiff appeals the defendant's final determination alleging that it was in error and without just cause for the following reason(s): 6. WHEREFORE, Plaintiff requests this honorable Court to grant the following relief: Date (Signature of attorney or plaintiff, if pro se) (Print name) (Street address) (City/Town) (State) (Zip) Tel. No. B.B.O. # CJ-D 310 (4/07) C.G.F. American LegalNet, Inc. www.FormsWorkflow.com