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UNIFORM ORDINANCE CITATION !w F2`1 y—dx <br /> BURNETT COUNTY SECTION 66.1190), WIS. STATUTES $ Forfeiture <br /> STATE OF WISCONSIN DEPOSIT PERMITTED B.C. 1294 $- , Penalty Assess. <br /> THE UNDERSIGNED,BEING DULY SWORN AND UNDER $r f Court Costs <br /> OATH,COMPLAINS FOR AND ON BEHALF OF THE <br /> COUNTY OF BURNETT UPON INFORMATION AND CIRCUIT COURT OF BURNETT COUNTY 3L' <br /> BELIEF,THAT ON OR ABOUT, $ �` r'/ TOTAL <br /> DAY OF WEEK I DATE VIOLATION I TIME ❑ AM I COUNTY TWP-VILLAGE-CITY <br /> r ❑ PM <br /> NAME LAST FIRST MI DATE OF BIRTH AGE <br /> L, I MO. DAY YR. <br /> STREET OR ROUTE CITY,STATE,ZIP CODE SEX ❑ M <br /> 'I 1 r_,,, ' ,-:k I ". LC�/S 'ems��. ❑ F <br /> DID UNLAWFULLY <br /> ON THE ABOVE STATED TIME,DATE AND LOCATION,THE DEFENDANT(DESCRIBE VIOLATION—STATE FACTS) <br /> { <br /> roc L! <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 /> A.M. THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS S <br /> ON J`14 19- AT IC� ❑ 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 />