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UNIFORM ORDINANCE CITATION <br /> BURNETT CDUNTY SECTION 66.119(1), WIS. STATUTES / <br /> Forfeiture <br /> STATE OF WISCONSIN DEPOSIT PERMITTED <br /> o v B.C. 1 $ Penalty Assess. <br /> THE UNDERSIGNED,BEING DULY SWORN AND UNDER l $ a Court Costs <br /> OATH,COMPLAINS FOR AND ON BEHALF OF THE <br /> COUNTY OF UPON INFORMATION AND <br /> BELIEFIEF,,THAT ON OR ABOUT, CIRCUIT COURT OF BURNETT COUNTY $ 03' 7 TOTAL <br /> THAT <br /> DAY OF WEEK I DATE VIOLATION I TIME ❑ AM I COUNTY­, J� " ":i�v_ <br /> VI LAG CIT <br /> ❑ PM tA1 'I ,o-ac(e <br /> NAME AST ST MI DATE OF BIRTH AGE <br /> ZE , <br /> l-u! G, C. I Mo. DAY YR. <br /> STREET OR ROUTEf r CITY STATE,ZIP CODE SEX M <br /> rCeO/Ir' i t! GAG f/E✓ 1 �z ❑ F <br /> DID UNLAWFULLY � r +< r _.L� r c .•, _;,.I:. �� „a, � ���T� r:< (,✓ 5., ; r �: <br /> O T,U .,ABOVE STATED TIME,D <br /> r TE#ND LOC4%TION,'THE DEFENDANT PE§CRIBS � <br /> -VIOLATJQN—. TATE FACTS) <br /> r i L " �'F-%/� i�'✓, �t 3/>i J r�`,�,r f'e-° (`.;. 1` ...� '7':.:J£<Gs,; s s-.'t:,1'5� r,�f� f;,x �yF� <br /> .✓' t:.2.&, "1"'�Lt t g.,��"- �'' r 6t..7i1 <br /> t�� ��/lnw^��,�~ i. ICY 4�C.� •"� � '1 s�+S..J'"..F ��Ll'f �. lr'�fx`�L39L.. � L�li¢CX�3 �.1-,,,� y�-i:! � � 7 w�lr <br /> c�INrS: j "1'1— J act,- �:7` S�A C ' <br /> in violation of sections r '�:l a" `' r I✓l of the ❑ f_ }G E ��'`UJA <br /> O 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 '`- 'dt✓t/ ` '`',e" r4 <br /> Name Title Department or Agency ' '"�y <br /> YOU ARE HEREBY NOTIFIED TO APPEAR IN THE <br /> ABOVE NAMED COURT 1, o <br /> THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS$ ' 1. / <br /> A <br /> .M. ; <br /> ON 19�—AT ❑ 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 /> SENDER: <br /> fl ■Complete items 1 and/or 2 for additional services. I also Wish to receive the <br /> ■Complete items 3,4a,and 4b. following services(for an <br /> ■Print your name and address on the reverse of this form so that we can return this extra fee): <br /> card to you. <br /> ■Attach this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address <br /> permit. <br /> y ■Write'Retum Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery N <br /> t ■The Return Receipt will show to whom the article was delivered and the date <br /> c delivered. Consult postmaster for fee. <br /> 3.Article Addressed to: 4a.Article Number <br /> PA Q1 <br /> )1 y 1 } j�'� 4b.Service Type / <br /> l(� I) ❑ Registered jE"�e�Hfied ¢ <br /> W 171 <br /> I r f�' (��� �t C � ❑ Express Mail ❑ Insured S <br /> c <br /> G ❑ ReturnReceipt for Merchandise ❑ COD <br /> 6-eden,c VILL 5W 3 <br /> 7.Date of Delivery ° <br /> Z <br /> c1 V. >? 1 �. <br /> M 5.Received By: (Print Name) 8.Addressee's Address(Only if requested <br /> p and fee is paid) t <br /> 6.Signature: (Addressee or Agent) <br /> PS Form 3811, December 1994 Domestic Return Receipt <br />