Section 2123.APPENDIX A   Caption for a Case Filed by the Office

STATE OF ILLINOIS

OFFICE OF THE STATE FIRE MARSHAL

OFFICE OF THE STATE FIRE MARSHAL                                   )

of the State of Illinois,                                     Complainant                )

                        v.                                                                     )           No.

(Name of Respondent)

(License Number)                                           Respondent                 )

C O M P L A I N T