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UNIFORM ORDINANCE CITATION <br /> BURNETT COUNTY SECTION 23.54, WIS. STATUTES FORM 4100-70 REV.9-80 <br /> — $ Forfeiture ' <br /> STATE OF WISCONSIN DEPOSIT PERMITTED <br /> B.C. N_ 2 91 $ Penalty Assess. <br /> �- �- <br /> THT 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 DATE VIOLATION TIME ❑ AM COUNTY CODE TWP-VILLAGE-CITY CODE ❑ WHI ❑ BLK ❑ NAT.AM. <br /> Q PM r ❑ ASN ❑ HSP ❑ NON-HSP <br /> NAME LAST FIRST. MI DATE OF BIRTH AGE EYES <br /> MO. DAY YR. HAIR <br /> STREET OR ROUTE CITY,STATE,ZIP CODE SEX ❑ M WGT. <br /> � - . '4 ;,c, /" e/ al ❑ F HGT. <br /> DID UNLAWFULLY r1 <br /> ON THE ABOVE STATED TIME, DATE AND LOCATION,THE DEFENDANT(DESCRIBE VIOLATION—STATE FACTS) <br /> G/'7 <br /> WA, <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 /> THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS$ " <br /> —.. l A.M. <br /> ON 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 />