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UNIFORM ORDINANCE CITATION b2 - ay'"v °�%' <br /> '.""BURNETT COUNTY SECTION 23.54, WIS. STATUTES FORM 4100-70 REV.9-80 <br /> $ Forfeiture <br /> pr. STATE OF WISCONSIN DEPOSIT PEWITTED �..) B.C. N2 122 $ 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 OF WEEK D TE V1 O ON TIME ❑ AM COUNTY CODE TWP-VILLAGE-CITY CODE ElWHI 1-1BLK ❑ NAT.AM. <br /> PM �I je,--- ❑ ASN ❑ HSP ElNON-HSP <br /> NAME LAS FIRST DATE OF BIRTH AGE EYES <br /> r— <br /> P ^), , ru C 4MO. DAY YR. HAIR <br /> STREET OR ROUTE CITY,STATE,ZIP CODE SEX .© M WGT. <br /> ❑ F HGT. <br /> DID UNLAWFULLY J;.-Y—- <br /> ON THE ABOVE STATED TIME,DATE AND LOCATION,THE DEFENDANT(DESCRIBE VIOLATION—STATE FACTS) <br /> in violation of section(s) �— '� of the ❑ Ordinance <br /> and prays that he/she may be held to answer therefor. ❑ BurneEC .ordinance ado,�hg sec _ <br /> Signature of Off�ice)r�l/ <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 /> ON 19—AT— ❑ P.M. THE COURT MAY ALSO REVOKE ALL LICENSES,CONFISCATE ALL EVIDENCE AND <br /> MY REQUIRE RESTORATION OR RESTITUTION OF ANY ENVIRONMENTAL DAMAGE. <br />