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UNIFORM ORDINANCE CITATION <br />BURNETT COUNTY SECTION 66.119(1), WIS. STATUTES <br />$ Forfeiture <br />DEPOSIT B <br />STATE OF WISCONSIN MITTED C <br />.. / � <br />$ Penalty Assess. <br />1 2 o :i <br />THE UNDERSIGNED, BEING DULY SWORN AND UNDER <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 />$ TOTAL <br />DAY OF WEEK <br />DATE VIOLATION <br />TIME ❑ AM <br />COUNTY <br />,WP -VILLAGE -CITY <br />I <br />El PM <br />". - <br />NAME LAST—FIRST _MI <br />1 n�► <br />DATE OF BIRTH <br />I <br />AGE <br />! t.! <br />MO. DAY YR. <br />STREET OR ROUTECITY, <br />ve <br />STATE, ZIP CODE <br />SEX M <br />OF <br />DID UNLAWFULLY <br />ON THE ABOVE ATED TIME, DA AND LOCATION THE DEFENDANT (DESCRIBE VIOLATION —STATE FACTS) <br />ty'%C <br />t' rcc�lrt Gt/t•/ t, (JRA Jts 4 <br />o1804, OAA-1.nKe F'Oc4f- Clustc. -f- Shu C11"f ufP_rI4t..,� GAS <br />7 rry xc���� ti r U T 3 0 GA,s d n' h �1 G— ��;; . 3S <br />r u� r!�{ur^. 1... 5 CrF it i <br />in violation of section(s) i - 411 j - <br />and prays that he/she may be held to answer therefor. <br />SUBSCRIBED AND SWORN TO Before me this date <br />Name Title — <br />YOU ARE HEREBY NOTIFIED TO APPEAR IN THE <br />ABOVE NAMED COURT <br />`o?f1Us A.M. <br />ON `� SPA lq — AT/ ❑ P.M. <br />BURNETT COUNTY GOVERNMENT CENTER <br />of the ❑ L-Af"CS U SC z0" 1„C -j/ Ordinance <br />❑ Burnett Co. ordin<ytce adopting sec. <br />Signature of Officer <br />19 Title 2— U ^, � <br />Department or Agency <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 />