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UNIFORM ORDINANCE CITATION <br /> BUP'IETT COUNTY SECTION 66.119(1), WIS. STATUTES <br /> $ Forfeiture <br /> STATE OF WISCONSIN DEPOSIT PERMITTED B.C. 1034 $ 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 I DATE VIOLATION TIME ❑ AM I COUNTY TWP-VILLAGE-CITY <br /> -< ❑ PM <br /> NAME LAST FIRST MI DATE OF BIRTH AGE <br /> MO. DAY YR. <br /> STREET OR ROUTE C/ITY�,STATE,ZIP C E SEX ❑ M <br /> 3 95- <br /> El 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 ❑ �� Y •X <br /> 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 /> j�� } <br /> THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS$ tO, ®� <br /> J}� A.M. <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 />