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UNIFORM ORDINANCE CITATION <br /> BURNETT COUNTY SECTION 23.54, WIS. STATUTES FORM 4100-70 REV.9-80 <br /> $ Forfeiture <br /> W STATE OF WISCONSIN DEPOSIT PERMITTED HO 9 <br /> B.C. 9 $ Penalty Assess. <br /> THE UNDERSIGNED,BEING DULY SWORN AND UNDER cl $ Court Costs <br /> OATH,COMPLAINS FOR AND ON BEHALF OF THE <br /> COUNTY OF BURNETT UPON INFORMATION AND CIRCUIT COURT OF BURNETT COUNTY $ ^ ?1' TOTAL <br /> BELIEF,THAT ON OR ABOUT, <br /> DAY OF WEEK DATE VIOLATION TIME �I AM BOUNTY CODE TWP-VILLAGE-CITY CODE ❑ WHI ❑ BLK ❑ NAT.AM. <br /> �� ❑ PM rj � ! `, ❑ ASN ❑ HSP ❑ NON-HSP <br /> NAME LAST FIR T -.MI DATE OF BIRTH AGE EYES <br /> i�. MO. DAY YR. HAIR <br /> STREET OR ROUTE { CITY,STATE,ZIP CODE SEX 4[T M WGT. <br /> .JG C3 ❑ F HGT. <br /> DID UNLAWFULLY - •.Y":r i/ , /� :: <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 A.M. �- <br /> THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS$ `` <br /> ON 4 r 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 />