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UNIFORM ORDINANCE CITATION <br /> BURNETT COUNTY SECTION 66.119(1), WIS. STATUTES r , <br /> $ Forfeiture <br /> STATE OF WISCONSIN DEPOSIT PERMITTED B.C. 1 2 0 0 $ 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 $ r �V TOTAL <br /> BELIEF,THAT ON OR ABOUT, <br /> D Y OF WEEK DATE VIOLATION TIME ❑ AM COUNTY TWP-VILLAGE-CITY <br /> PM 1 <br /> NAME ��}} LAST FIRST /MI DATE OF BIRTH / AGE <br /> )014 11 /4 e— l/U `r MO. S DAY GP YR. <br /> STREET OR ROUTE yy CITY,STATE,ZIP CODE SEX ❑ M <br /> DID UNLAWFULLY <br /> ON THE ABOVE STATED TIME,DATE AND�LLOCATION,THE DEFENDANT(DESCRIBE VIOLATION—STATE FACTS) t <br /> tie rGct L�(.�n) /srtlti� +�� 4 7 rrz <br /> 15, rn <br /> in violation of section(s) L ` 1 rt 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 JMr <br /> Name Title Department or Agency <br /> YOU ARE HEREBY NOTIFIED TO APPEAR IN THE <br /> ABOVE NAMED COURT v; <br /> A.M. <br /> THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS S <br /> / <br /> -�^ / � <br /> ON /F�` ) 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 />