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UNIFORM ORDINANCE CITATION <br /> BURNETT COUNTY SECTION 66.119(1),WIS.STATUES <br /> $ �`r� <br /> e-c• — Forfeiture <br /> t, '"!, STATE OF WISCONSIN DEPOSIT PERMITTED B.C. 2114 $ L c( 5L Penalty Asses. <br /> Tilt UNDERSIGNED,BEING DULY SWORN AND UNDER $ Court Costs <br /> OATH,COMPLAINS FOR AND ON BEHALF OF THE <br /> COUNTY OF BURNETT UPON INFORMATION AND CIRCUIT COURT OF BURNETT COUNTY S `}' Y'"47' TOTAL <br /> BELIEF,THAT ON OR ABOUT, <br /> DAY OF WEEK DATE VIOLATION TIME lil AM COUNTY TWP-VILLAGE-CITY <br /> ❑ PM = .<7, <br /> NAME LAST FIRST M I DATE OF BIRTH AGE <br /> MO. DAY YR. <br /> STREET OR ROUTE CIT STATE,ZIP CODE SEX ❑ \1 <br /> �" f ❑ F <br /> DID UNLAWFULLY 4 , . <br /> . <br /> ON THE ABOVE STATED TIME.DATE AND LOCATION.THE DEFENDANT(DESCRIBE VIOLATION-STATE FACTS) <br /> 'U <br /> in violation of section(s) 4. '' of the ❑ Ordinance <br /> and prays that he/she may be held to answer therefore. ❑ Burnett Co.ordinance adopting sec. <br /> Signature of Officer <br /> SUBSCRIBED AND SWORN TO Before me this date 20 Title <br /> Name Title Department or Agency'4'a'�''I' <br /> ' ` ', E;:` { ' '�t <br /> YOU ARE HEREBY NOTIFIED TO APPEAR IN THE <br /> ABOVE NAMED COURT r i` a^wr <br /> THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS$ <br /> A.M. <br /> ON T 20 1 3 AT, ❑ P.M. THE COURT MAY ALSO REVOKE ALL LICENSES,CONFISCATE ALL EVIDENCE AND <br /> BURNETT COUNTY GOVERNMENT CENTER REQUIRE RESTORATION OR RESTITUTION OF ANY ENVIRONMENTAL DAMAGE. <br />