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UNIFORM ORDINANCE CITATION <br /> BURNETT COUNTY SECTION 66.1190), WIS. STATUTES $ Forfeiture <br /> STATE OF WISCONSIN DEPOSIT PERMITTED B.C. 1320 $ 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 /> BELIEF,THAT ON OR ABOUT, $ TOTAL <br /> DAY OF WEEK DATE VIOLATION TIME ❑ AM COUNTY FTW <br /> P-VILLAGE-CITY <br /> -g-,, ❑ PM <br /> a' <br /> NAME LAST FIRST MI DATE OF BIRTH AGE <br /> r f „ MO. DAY YR. <br /> STREET OR ROUT `/ CITY,STATE,ZIP CODE SEX ❑ M <br /> f lf�.rt, t- t� ❑ 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) 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 /> El A.M. THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS$ <br /> ON 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 />