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UNIFORM ORDINANCE CITATION Q/&—YY01'Oy_ 710 S <br /> BURNETT COUNTY SECTION 23.54, WIS. STATUTES FORM 4100-70 REV.9-80 <br /> $ Forfeiture <br /> STATE OF WISCONSIN DEPOSIT PERMITTED B.C. N2 154 $ 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 /> BEL( F THAT ON OR ABOUT, $ TOTAL <br /> DAY OF WEEK DATE VIOLATION I TIME ❑ AM I COUNTY CODE TWP-VILLAGE-CITY CODE ❑ WHI ❑ BLK ❑ NAT.AM. <br /> El PM ❑ 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 /> 1 +- 2 ❑ F HGT. <br /> DID UNLAWFULLY <br /> ON THE ABOVE STATED TIME,DATE AND LOCATION,THE DEFENDANT(DESCRIBE VIOLATION—STATE FACTS) <br /> in violation of section(s) of the ❑ , (tt - + -{ - x ,q Ordinance <br /> and prays that he/she may be held to answer therefor. ❑ 1 Burnett Co.ordinance adopting sF. <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 /> 91 A.M. <br /> THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS <br /> j $ <br /> ON A 1-'•(I 2 r 19 AT L ❑ P.M. THE COURT MAY ALSO REVOKE ALL LICENSES,CONFISCATE ALL EVIDENCE AND <br /> CITY �_' `Y+ ' 'r' REQUIRE RESTORATION OR RESTITUTION OF ANY ENVIRONMENTAL DAMAGE. <br />