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UNIFORM ORDINANCE CITATION <br /> BURNETT COUNTY SECTION 23.54, WIS. STATUTES FORM 4100-70 REV.9-80 <br /> $ Forfeiture <br /> STATE OF WISCONSIN DEPOSIT PERMITTED B. <br /> C. NQ 2 1 4 $ 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 /> D Y OF WEEK I DATE VIOLATION TIME ❑ AM CODE LTWP-VILLAGE-CITY CODE ElWHI ❑ BLK ❑ NAT.AM. <br /> PM �9UNTY <br /> 44lf/t-'C f ❑ ASN ❑ HSP ❑ NON <br /> NAME LAST FIRST DATE OF BIRTH AGE EYES <br /> L4 7- MO. DAY YR. HAIR <br /> STREET OR ROUTE' CITY,STATE,ZIP CODE - SEX ❑ M WGT. <br /> j� r - HGT. <br /> DID UNLAWFULLY a. `;?e <br /> ON THE ABOVE STATED TIME,DATE AND LOCATION,THE DEFENDANT(DESCRIBE VIOLATION—STATE FACTS) <br /> " <br /> L" 1 �p <br /> in violation of section(s) ` ""°i of the ❑ +-• ' t` ��' Ordinance 1� <br /> and prays that he/she may be held to answer therefor. ❑ Burnett Co.ordinance adopting sec. <br /> Signature of Officer <br /> t� �, ,/�► <br /> SUBSCRIBED AND SWORN TO Before me this date �+�� �^•^ �"t' 19� Title �r j <br /> Name ? :: / r.,. Title :.. ^L: ;%f Department or Agency r! L <br /> YOU ARE HEREBY NOTIFIED TO APPEAR IN THE <br /> ABOVE NAMED COURT r <br /> THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS$ <br /> A.M. <br /> ON 19 " AT ❑ P.M. THE COURT MAY ALSO REVOKE ALL LICENSES,CONFISCATE ALL EVIDENCE AND <br /> CITY V,R REQUIRE RESTORATION OR RESTITUTION OF ANY ENVIRONMENTAL DAMAGE. <br />