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UNIFORM ORDINANCE CITATION <br /> BURNETT COUNTY SECTION 66.1190), WIS. STATUTES $ - Forfeiture <br /> STATE OF WISCONSIN DEPOSIT PERMITTED B.C. 0 2 3 $ 41) - 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 /> U <br /> BELIEF,THAT ON OR ABOUT, $ 'r 0 TOTAL <br /> AY OF WEEK DATE VIOLATION TIME ❑ AM COUNTY TWP-VILLAGE-CITY <br /> v — <br /> NAME LAST, FIRST MI DATE OF BIRTH AGE <br /> r� MO. DAY YR. <br /> STREET OR ROUTE CITY,STATE,ZIP CODE SEX ❑ M <br /> 1 <br /> DID UNLAWFULLY _"j\'f1 t--) .,,,+' <br /> ON THE ABOVE STATED TIME,DATE AND LOCATION,THE DEFENDANT(DESCRIBE VIOLATION—STATE FACTS) <br /> �- <br /> 0 <br /> in violation of section(s) LF ' ! 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 /> I <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$ <br /> 1� A.M. <br /> ON 19 AT L ❑ 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 />