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UNIFORM ORDINANCE CITATION G A�- <br /> BURNETT COUNTY SECTION 23.54, WIS. STATUTES FORM-�9-so <br /> $ Forfeiture <br /> STATE OF WISCONSIN DEPOSIT PERMITTED B.C. NO 137 $- 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 OFWEEK DATE VIOLATION I TIME ❑ AM COUNTY CODE TWP-VILLAGE-CITY CODE ❑ WHI ❑ BLK ❑ NAT.AM. <br /> i.'` El PM <br /> ❑ ASN ElHSP ❑ 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 /> ❑ F HGT. <br /> DID UNLAWFULLY Ma,,f <br /> ON THE ABOVE STATED TIME,DATE AND LOCATION,THE DEFENDANT(DESCRIBE VIOLATION—STATE FACTS) <br /> J{- G <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 <br /> Title --� <br /> Name Title Department or Agency <br /> YOU ARE HEREBY NOTIFIED TO APPEAR IN THE <br /> ABOVE NAMED COURT <br /> A.M. THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS$ <br /> THE COURT MAY ALSO REVOKE ALL LICENSES,CONFISCATE ALL EVIDENCE AND <br /> CITY REQUIRE RESTORATION OR RESTITUTION OF ANY ENVIRONMENTAL DAMAGE. <br />