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UNIFORM ORDINANCE CITATION <br /> BURNETT COUNTY SECTION 66.119(1), WIS. STATUTES <br /> $ Forfeiture <br /> STATE OF WISCONSIN DEPOSIT PERMITTED B.C. i 2 31 $ tJ • 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 DATE VIOLATION TIME ❑ AM COUNTY TWP-VILLAGE-CITY <br /> PM /47: I <br /> NAME LAST FIRST MI DATE OF BIRTH AGE <br /> f:%f.,/ `/C"_-�.,... MO. DAY YR. <br /> STREET OR ROUTE CITY,STATE,ZIP CODE SEX ❑ M <br /> a � — r _. ❑ F <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 ❑ Ordinance <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 /> 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 /> Ai A.M. <br /> ON °..,.t' 39—AT f ,,' ❑ P.M. <br /> 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 />