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UNIFORM ORDINANCE CITATION <br /> BURNETT COUNTY SECTION 23.54, WIS. STATUTES FORM 4100-70 REV.9-80 <br /> $ Forfeiture <br /> _ STATE OF WISCONSIN DEPOSIT PERMITTED B.C. NQ 196 $ Penalty Assess. <br /> THE UNDERSIGNED,BEING DULY SWORN AND UNDER 1, $ 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 /> Y OF-WEEK DATE VIOLATION TIME ❑ AM COUNTY f CODE TWP-VILLAGE-CITY CODE ❑ WHI ❑ BLK ElNAT.AM. <br /> ❑ ASN ❑ HSP ❑ NON-HSP <br /> NAME ;LAST FIRST MI DATE OF BIRTH AGE EYES <br /> MO. DAY YR. HAIR <br /> STREET.OR ROUTE r 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 /> r <br /> 7 <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$ <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 />