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UNIFORM ORDINANCE CITATION <br /> BURNETT COUNTY SECTION 66.119(1), WIS. STATUTES <br /> $ Forfeiture <br /> STATE OF WISCONSIN DEPOSIT PERMITTED. B.0 $ M Penalty Assess. <br /> THE UNDERSIGNED,BEING DULY SWORN AND UNDER / ' 1047 <br /> $— .+--� Court Costs <br /> OATH,COMPLAINS FOR AND ON BEHALF OF THE -- <br /> COUNTY OF BURNETT UPON INFORMATION AND CIRCUIT COURT OF BURNETT COUNTY '�� � m <br /> BELIEF,THAT ON OR ABOUT, $j�__I3 TOTAL <br /> DAY OF WEEK I DATE VIOLATION I TIME ❑ AM COUNTY TWP-VILLAGE-CITY <br /> ❑ PM <br /> NAME LAST FIRST MI DATE OF BIRTH AGE <br /> ,t ' MO. DAY YR. <br /> STREET OR ROUTE CITY,STATE,ZIP CODE SEX ❑ M <br /> DID UNLAWFULLY <br /> ON THE ABOVE STATED TIME,DATE AND LOCATION,THE DEFENDANT(DESCRIBE VIOLATION—STATE P�CTS) <br /> i <br /> ems; <br /> in violation of section(s) of the ❑ Ordinance �,�„r���) <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 11 a <br /> THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS S <br /> ,FA.M. <br /> ON 19 AT/-0— ❑ 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 />