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UNIFORM ORDINANCE CITATION <br /> BURNETT COUNTY SECTION 66.119(1), WIS. STATUTES $ Forfeiture <br /> STATE OF WISCONSIN DEPOSIT PERMITTED B.C. 1028 <br /> $ Penalty Assess. <br /> THE UNDERSIGNED,BEING DULY SWORN AND UNDER Ca <br /> $ 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 DATE VIOLATION I TIME ❑ AM CO NTY TW V�G- ITY <br /> GT ..�' 77 PM Poe— of <br /> NAME LAST FIRST MI DATE OF BIRTH AGE <br /> A t7ld j MO. DAY YR. <br /> STREET OR ROUTE C Y,STATE,ZIP CODE SEX <br /> �O r e �1�tU��: R, 3 a F <br /> DID UNLAWFULLY 4 , 4- I.4ly <br /> ON T E ABOVE STATED TIME,DATE AND LOCATION,THE DEFENDANT(DESCRIBE VIOLATIO —STATE FACTS) <br /> B NS! i-t ! ,t E ' <br /> t LL6 i—.$dI-N <br /> in violation of section(s) �` ,' of the ❑ ULOrdinance <br /> and prays that he/she may be held to answer therefor. ❑ Burnett Co.ordinance adopting sec. <br /> Signature of Officer <br /> SUBSCRIBED AND SWORN TO Before me this date 19 Title <br /> ( l! <br /> Name Title Department or Agency <br /> YOU ARE HEREBY NOTIFIED TO APPEAR IN THE <br /> ABOVE NAMED COURT �` 40 <br /> THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS$ ✓ ' �� <br /> �.i? A.M. <br /> ON�� 19�AT A/W❑ 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 />