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UNIFORM ORDINANCE CITATION <br />BURNETT COUNTY SECTION 23.54, WIS. STATUTES <br />STATE OF WISCONSIN DEPOSIT PERMITTED <br />THE UNDERSIGNED, BEING DULY SWORN AND UNDER I I —IT` J " <br />OATH, COMPLAINS FOR AND ON BEHALF OF THE <br />COUNTY OF BURNETT UPON INFORMATION AND <br />BELIEF, THAT ON OR ABOUT, <br />DAY OF WEEK I DATE VIOLATION I TIME V AM CQU <br />❑ PM ` <br />NAME f�J LAST... —F FIRST <br />FORM 4100-70 REV. 9-80 <br />B.C. N2 344 <br />CIRCUIT COURT OF BURNETT COUNTY <br />CODE TWP-VILLAGE-CITY <br />yr'.. - r^ ; j <br />e ,, <br />MI DATE OF BIRTH <br />MO. DAY YR. <br />$ `" a Forfeiture <br />$ Penalty Assess. <br />$ Court Costs <br />$'? TOTAL <br />CODE ❑ WHI ❑ BLK ❑ NAT. AM. <br />❑ ASN ❑ HSP ❑ NON -HSP <br />AGE EYES <br />HAIR <br />STREET OR//ROUTE CITY, STATE, ZIP CODE SEX M WGT. <br />Z, <br />`U' f ` ^ LUt' (1,�i' t El HGT. <br />t' <br />DID UNLAWFULLY, ! f 8 , t , U t <br />ON THE ABOVE STATED TIME, DATE AND LOCATION, THF,—DEFENDANT (DESCRIBE VIOLATION — STATE FACTS) <br />in violation of section(s) of the ❑ ' ` Ordinance <br />and prays that he/she may be held to answer therefor. ❑ Burnett Co. ordinance adopting sec. <br />Signature of Officer.' <br />SUBSCRIBED AND SWORN TO Before me this date 19 Title <br />Name Title — <br />YOU ARE HEREBY NOTIFIED TO APPEAR IN THE <br />ABOVE NAMED COURT <br />ON <br />CITY <br />A. M. <br />19 — AT/_ ❑ P.M. <br />Department or Agency 'A <br />THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS $ <br />THE COURT MAY ALSO REVOKE ALL LICENSES, CONFISCATE ALL EVIDENCE AND <br />REQUIRE RESTORATION OR RESTITUTION OF ANY ENVIRONMENTAL DAMAGE. <br />SENDER: <br />• Complete items 1 and/or 2 for additional services. I also wish to receiN, <br />• Complete items 3, and 4a & b. following services (for ar <br />• Print your name and address on the reverse of this form so fee): <br />that we can return this card to you. 1. ❑Addressee's Adt <br />• Attach this form to the front of the mailpiece, or on the <br />back if space does not permit. <br />• Write "Return Receipt Requested" on the mailpiece next to 2. ❑ Restricted Delive <br />the article number. Consult postmaster for fe <br />3. Article Addressed to: <br />1e. <br />Ke Elerd Kd. <br />5. Signature (Addressee) <br />6. Sjq.nature <br />4a <br />rticle Number <br />4b. Service Type <br />❑ Registered ❑ Insured <br />ertified ❑ COD <br />Express Mail ❑ Return Recei <br />Merchandise <br />7. Date of elivery <br />8. Addressee's Address (Only if re, <br />and fee is paid) <br />PS Form :3611, October 1990 *U.S. GPO: 1990-273-861 DOMESTIC RETURN RE <br />�� s led <br />