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UNIFORM ORDINANCE CITATION <br /> �BORNETT COUNTY SECTION 23.54, WIS. STATUTES FORM 4100-70 REV.9-80 <br /> $ Forfeiture <br /> STATE OF WISCONSIN DEPOSIT PERMITTED B.C. $ �� Penalty Assess. <br /> � <br /> THE UNDERSIGNED,BEING DULY SWORN AND UNDER 2 0 $ T Court Costs <br /> OATH,COMPLAINS FOR AND ON BEHALF OF THE <br /> COUNTY OF BU UPON INFORMATION AND <br /> BELIEFF,,THAT ON OR ABOUT, CIRCUIT COURT OF BURNETT COUNTY �� DU THAT $ TOTAL <br /> DAY OF WEEK DATE /VIOLATION ITIME-0 AM COUNTY CODE T P-VILLAGE-CITY CODE <br /> /V d " /S— D PM 'y �,. ❑ WHI ❑ BLK ❑ NAT.AM. <br /> ❑ASN ❑ HSP ❑ NON-HSP <br /> NAME LAST IRST MI DATE OF BIRTH AGE EYES <br /> jaere /U MO. DAY YR. HAIR <br /> STREET OR ROUTE CITY,STATE,ZIP CODE 5.3 6,0;� SEX -4n;M WGT. <br /> F HGT. <br /> DID UNLAWFULLY <br /> ON THE ABOVE STATED T,IIME,DATE AND LOCATION,THE DEFENDANT(DESCRIBE VIOLATION—STATE FACTS) <br /> Sc <br /> in violation of section(s) �� ��'I of the ❑J Ordinance <br /> and prays that he/she may be held to answer therefor. Ll 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 �seo <br /> YOU ARE HEREBY NOTIFIED TO APPEAR IN THE <br /> ABOVE NAMED COURT <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 /> C"'fTX,h' REQUIRE RESTORATION OR RESTITUTION OF ANY ENVIRONMENTAL DAMAGE. <br />