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UNIFORM ORDINANCE CITATION o1(p- S'i'"'' �"�" v ` v <br /> BURNETT COUNTY SECTION 23.54, WIS. STATUTES FORM 4100-70 REV.940 <br /> $ Forfeiture <br /> STATE OF WISCONSIN DEPOSIT PERMITTED B.C. NQ 103 $ Penalty Assess. <br /> THE UNDERSIGNED,BEING DULY SWORN AND UNDER $ Court Costs <br /> OATH,COMPLAI4-FOR-AND ON BEHALF OF THE <br /> COUNTY OF BURNETT UPON INFORMATION AND CIRCUIT COURT OF BURNETT COUNTY <br /> BELIEF,THAT ON OR ABOUT, $ TOTAL <br /> DAY OF WEEK DATE VIOLATION TIME ❑ AM COUNTY CODE TWP-VILLAGE-CITY CODE ElWHI ElBLK ❑ NAT.AM. <br /> N <br /> PM ❑ ASN ❑ HSP ❑ NON-HSP <br /> NAME LAST FJRST MI DATE OF BIRTH AGE EYES <br /> MO. DAY YR. HAIR . <br /> STREET OR ROUTE CITY,STATE,ZIP CODE SEX ❑ M WGT. <br /> -_.' F /... <br /> DID UNLAWFULLY <br /> ON THE ABOVE STATED TIME,DATE AND LOCATION,THE DEFENDANT(DESCRIBE VIOLATION—STATE FACTS) <br /> in violation of section(s) j' 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 ��J <br /> THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS$ <br /> A.M. <br /> ON 19—AT— ❑ P.M. THE COURT MAY ALSO REVOKE ALL LICENSES,CONFISCATE ALL EVIDENCE AND <br /> CITY REQUIRE RESTORATION OR RESTITUTION OF ANY ENVIRONMENTAL DAMAGE. <br />