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UNIFORM ORDINANCE CITATION <br /> BURNETT COAd/ SECTION 23.54, WIS. STATUTES FORM 4100-70 REV.9-80 <br /> a Forfeiture <br /> OF WISCONSIN DEPOSIT PERMITTED B.C, NO 298 $ Penalty Assess. <br /> TH <br /> E UNDE ' BEING DULY SWORN AND UNDER -`j` $ Court Costs <br /> OATH, INS FOR AND ON BEHALF OF THE <br /> COUN RNETT UPON INFORMATION AND CIRCUIT COURT OF BURNETT COUNTY $ 'J' TOTAL <br /> IEF,THAT ON OR ABOUT, <br /> DAY OF WEEK I DATE VIOLATION TIME ❑ AM COUNTY CODE TWP-VILLAGE-CITY CODE ❑ WHI ❑ BLK ❑ NAT.AM. <br /> ❑ PM r ❑ ASN ❑ HSP ❑ NON-HSP <br /> NAME LAST FIRST _MI DATE OF BIRTH AGE EYES <br /> MO. DAY YR. HAIR <br /> STREET OR ROUTE CITY,ST�TE,ZIP CODE SEX [,-IM WGT. <br /> El F <br /> ^� i r <br /> DID UNLAWFULLY <br /> ON THE ABOVE STATED TIME,DATE AND LOCATION,THE DEFENDANT(DESCRIBE VIOLATION—STATE FACTS) <br /> f: <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 /> THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS$ F `' <br /> � / A.M. <br /> ON f ` 19 IL ATE': ❑ P.M. THE COURT MAY ALSO REVOKE ALL LICENSES,CONFISCATE ALL EVIDENCE AND <br /> CITY r Al. `i^ i REQUIRE RESTORATION OR RESTITUTION OF ANY ENVIRONMENTAL DAMAGE. <br />