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UNIFORM ORDINANCE CITATION <br /> BURNETT COUNTY SECTION 66.119(1), WIS. STATUTES <br /> $ Forfeiture <br /> STATE OF WISCONSIN DEPOSIT PERMITTED B.C. $ Penalty Assess. <br /> THE UNDERSIGNED,BEING DULY SWORN AND UNDER 1 -' <br /> OATH,COMPLAINS FOR AND ON BEHALF OF THE $ Court Costs <br /> COUNTY OF BURNETT UPON INFORMATION AND -,, p. f <br /> BELIEF,THAT ON OR ABOUT, CIRCUIT COURT OF BURNETT COUNTY <br /> $ TOTAL <br /> DAY OF WEEK I DATE VIOLATION I TIME ❑ AM COUNTY TWP-VILLAGE-CITY <br /> ❑ PM , <br /> NAME LAST FIRST MI DATE OF BIRTH AGE <br /> A'..)'Lt_( r' MO. DAY YR. <br /> STREET OR ROUE CITY,STATE,ZIP CODE SEX ❑ M <br /> ❑ F <br /> DID UNLAWFULLY MO& <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 /> t . THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS$ / <br /> ON 4lc t a,iu ElA.M. <br /> T9"_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 />