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UNIFORM ORDINANCE CITATION <br /> BURNETT COUNTY SECTION 66.119(1), WIS. STATUTES <br /> -z $ .��;�0 - Forfeiture <br /> STATE OF WISCONSIN DEPOSIT PERMITTED B.C. 1021 $� 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 /> I BELIEF,THAT ON OR ABOUT, $ ��'' TOTAL <br /> DAY OF WEEK DATE VIOLATION TIME ❑ AM COUNTY TWP-VILLAGE-CITY <br /> r uL r ? PM /lam -'..s.. •':.; <br /> NAME LAST FIRST MI DATE OF BIRTH AGE <br /> MO. DAY YR. <br /> STREET Og ROUTE CITY,STATE,ZIP CODE SEX <br /> T ./ /7-o t Ie El <br /> DID UNLAWFULLY ��, f r,:r '74 ..1 r .. A? t <br /> ON THE ABOVE STATED TIME,DATE AND LOCATION,THE DEFENDANT(DESCRIBE VIOLATION—STATE FACTS) <br /> r <br /> Lf <br /> i <br /> in violation of sections) of the ❑ Cl Ordinance <br /> and prays that he/she may be held to answer therefor. ❑ Burnett Co.ordinance adopting sec. <br /> Signature of Officer <br /> r <br /> SUBSCRIBED AND SWORN TO Before me this date 19 Title i <br /> Name Title Department or Agency r <br /> YOU ARE HEREBY NOTIFIED TO APPEAR IN THE <br /> ABOVE NAMED COURT <br /> THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS$ I,✓' ♦/ t <br /> ON - 'Y" 19—AT Fe ❑ 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 />