Laserfiche WebLink
UIV11'VKm UKOUNAPIU II11A11VIN <br />BURiC,M COUNTY SECTION 23.54, WIS. STATUTES FORM 4100-70 REV. 9-80 <br />$ Forfeiture <br />,,TATE OF WISCONSIN DEPOSIT PERMITTED B.C. / $ 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 <br />BELIEF, THAT ON OR ABOUT, $ TOTAL <br />DAY OF WEEK I DATE VIOLATION TIME ❑ AM COUNTY CODE TWP-VILLAGE-CITY CODE ❑ WHI ❑ BLK ❑ NAT. AM. <br />9 PM ❑ ASN ❑ HSP ❑ NON -HSP <br />NAME LAST FIRST full DATE OF BIRTH AGE EYES <br />MO. DAY YR. HAIR <br />STREET OR ROUTE CITY, STATE, ZIP CODE SEX ^ M WGT. <br />F HGT. <br />DID UNLAWFULLY <br />ON THE ABOVE STATED TIME, DATE AND LOCATION, THE 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 Department or Agency <br />YOU ARE HEREBY NOTIFIED TO APPEAR IN THE <br />ABOVE NAMED COURT <br />A.M. S <br />' THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS $ �[/ ✓✓ <br />�l❑ <br />ON 1 19 — AT'_ ❑ P.M. THE COURT MAY ALSO REVOKE ALL LICENSES, CONFISCATE ALL EVIDENCE AND <br />CITY REQUIRE RESTORATION OR RESTITUTION OF ANY ENVIRONMENTAL DAMAGE. <br />