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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 v $13 <br /> OATH,COMPLAINS FOR AND ON BEHALF OF THE Court Costs <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 ---TTWP-VILLAGE-CITY <br /> PM <br /> NAME LAST .t FIRST MI DATE OF BIRTH AGE ',1(a F V ✓ <br /> i t C_Aa - I MO. DAY YR. <br /> STREET OR ROUTTE� CITY,STATE,ZIP CODE SEX 0 M <br /> J PJt Q4 t 3v ❑ F <br /> DID UNLAWFULLY ,ter ,r�64C iyr e 1/^� i1F f r <br /> ON THE ABOVE STATED TIME,DATE AND LOCATION,THE DEFENDANT(DESCRIBE VIOLATION—STATE FACTS) <br /> ' e .,' f a <br /> in violation of section(s) of the ❑ v <br /> Ordinance .>i•6>75 Gl e—`J <br /> and prays that he/she may be held to answer therefor. ❑ Burnett Co.ordinance adopting sec. <br /> j <br /> Signature of Officer j r <br /> SUBSCRIBED AND SWORN TO Before me this date 19 <br /> Title•--"'""�J <br /> Name Title Department or Agency '" <br /> YOU ARE HEREBY NOTIFIED TO APPEAR IN THE <br /> ABOVE NAMED COURT <br /> El A.M. THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS S / x <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 />