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UNIFORM ORDINANCE CITATION <br /> BURNETT COUNTY SECTION 66.1190), WIS. STATUTES $ �- Forfeiture <br /> DEPOSIT PERMITTED `� i 4 3 $ Y� '� Penalty Assess. <br /> ' STATE OF WISCONSIN B.C. v �`� <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 $ 'U TOTAL <br /> BELIEF,THAT ON OR ABOUT, <br /> DAY OF WEEK I DATE VIOLATION I TIME ❑ AM I COUNTY TWP-VILLAGE-CITY <br /> ` ❑ PM <br /> NAME LAST FIRST , I DATE OF BIRTH AGE <br /> ,/ QA-i MO. DAY YR. <br /> STREET OR ROUTE CITY,STATE,ZIP CODE SEX ❑ M <br /> f-f� Eat r r ( ❑ F <br /> DID UNLAWFULLY <br /> ON THE ABOVE STATED TIME,DATE AND LOCATION,THE DEFENDANT(DESCRIBE VIOLATION—STATE FACTS) 1 <br /> � . ; � <br /> 1 <br /> l <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 /> V 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 /> VE NAMED COURT <br /> THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS$ <br /> ` A.M. <br /> ON 19 AT f 0 ❑ 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 />