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UNIFORM ORDINANCE CITATION <br />BURNETT COUNTY SECTION 23.54, WIS. STATUTES FORM 4100-70 REV. 9-80 <br />$ l=� <br />Forfeiture <br />STATE OF WISCONSIN <br />DEPOSIT PERMITTED d <br />+' <br />B C N2 145 <br />$ <br />Penalty Assess. <br />TH$ 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 <br />CIRCUIT COURT OF BURNETT COUNTY <br />J <br />BELIEF, THAT ON OR ABOUT, <br />$ <br />TOTAL <br />DAY j(EEK <br />DATE VIOLATION <br />TIME ❑ AM <br />COUNTY <br />CODE <br />TWP-VILLAGE-CITY <br />CODE <br />❑ WHI <br />❑ BLK <br />❑ NAT. AM. <br />'OF <br />1 t G <br />fl PM <br />%F 1 (`_'s <br />❑ ASN <br />❑ HSP <br />❑ NON-HSP <br />NAME LAST FIRST MI <br />DATE OF BIRTH <br />AGE <br />EYES <br />T <br />r; r> <br />MO. DAY YR. <br />HAIR <br />STREET OR ROUTE <br />CITY, STATE, ZIP CODE <br />SEX K M <br />WGT. <br />DID UNLAWFULLY <br />ON THE ABOVE STATED TIME, DATE AND LOCATION, THE DEFENDANT (DESCRIBE VIOLATION — STATE FACTS) <br />in violation of section(s) _A ' ` , , -- of the ❑ <br />and prays that he/she may be held to answer therefor. ❑ <br />SUBSCRIBED AND SWORN TO Before me this date 19 <br />Name Title <br />YOU ARE HEREBY NOTIFIED TO APPEAR IN THE <br />A OV ED COURT <br />THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS $ <br />l A.M. <br />ON 19 AT t ;� ❑ P.M. THE COURT MAY ALSO REVOKE ALL LICENSES, CONFISCATE ALL EVIDENCE AND <br />CITY REQUIRE RESTORATION OR RESTITUTION OF ANY ENVIRONMENTAL DAMAGE. <br />Ordinance <br />Burnett Co. ordinance adopting sec. <br />Signature of Officer <br />Title <br />Department or Agency <br />