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UNIFORM ORDINANCE CITATION <br />BURNETT COUNTY SECTION 23.54, WIS. STATUTES FORM 4100-70 REV. 9-80 <br />$ <br />Forfeiture <br />' STATE OF WISCONSIN DEPOSIT PERMITTED B.C. NO 310 <br />$ <br />Penalty Assess. <br />THE UNDERSIGNED, BEING DULY SWORN AND UNDER �/ ' <br />$ <br />Court Costs <br />OATH, COMPLAINS FOR AND ON BEHALF OF THE <br />COUNTY OF BURNETT UPON INFORMATION AND CIRCUIT COURT OF BURNETT COUNTY <br />BELIEF, THAT ON OR ABOUT, <br />S <br />TOTAL <br />D Y OF WEEK <br />DATE VIOLpATION <br />TIME X1 AM <br />C UNTY <br />CODE <br />TWP-VILLAGE-CITY <br />CODE <br />❑ WHI <br />❑ BLK ❑ NAT. AM. <br />I — / <br />I ❑ PM <br />j/✓� <br />• •/ <br />/9 <br />'� <br />❑ ASN <br />❑ HSP ❑ NON-HSP <br />EYES <br />NAME, i LAST FIRST MI <br />DATE OF BIRTH <br />AGE <br />;` -� I-- R ^� <br />T <br />MO. DAY YR. <br />HAIR <br />WGT. <br />STR ET OR,,R//OUTE <br />CITY, STATE, ZIP CODE <br />SEX )J M <br />Tl ! <br />�' r' if/ i ��z'' <br />❑ F <br />HGT. <br />DID UNLAWFULLj&4: Q// t- exp ' t c TlyAs ' <br />ON THE ABOVE STATED TIME, DATE AND LOCATION, THE DEFENDANT (DESCRIBE VIOLATION — STATE FACTS) <br />in violation of section(s)�' �' L' of the Ordinance <br />and prays that he/she may be held to answer therefor. ] ' `� Burnett Co. ordinance adopting",{ 1-1 t � ! - <br />c.�,t <br />Signature of Officer <br />SUBSCRIBED AND SWORN TO Before me this date 19 Title <br />Name Title Department or Agency— <br />YOU <br />gency YOU ARE HEREBY NOTIFIED TO APPEAR IN THE <br />ABOVE NAMED COURT <br />A.M. <br />ON 19 AT ❑ P.M. <br />CITY <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 />