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UNIFORM ORDINANCE CITATION <br />BURNETT COUNTY SECTION 66.119(1), WIS. STATUTES $ Forfeiture <br />STATE OF WISCONSIN DEPOSIT PERMITTED B.C. 1 0 1 1 $ Penalty Assess. <br />THE 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 j` <br />BELIEF, THAT ON OR ABOUT, $ TOTAL <br />DAY OF WEEK DATE VIOLATION TIME ❑ AM CO TY TWP-VILLAGE-CITY <br />© PM _ ._.. <br />ltir_c <br />NAME LAST FIRST MI DATE OF BIRTH AGE <br />MO. DAY YR. <br />STREET OR ROUTE CITY, STATE, ZIP CODE SEX ❑ M <br />❑ F <br />DID UNLAWFULLY t , <br />ON THE ABOVE STATED TIME, DATE AND LOCATION, THE DEFENDANT (DESCRIBE VIOLATION — STATE FACTS) <br />�r <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 TitleI+ <br />Name Title Department or Agency <br />YOU ARE HEREBY NOTIFIED TO APPEAR IN THE <br />ABOVE NAMED COURT ' d 7 Cr 4 j <br />A.M. THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS $ l <br />ON 19 ATL ❑ 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 />