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---- UNIFORM ORDINANCE CITATION U tj'-f-«i-` -u' ''` O A-k.. __�/ <br /> BURNETT COUNTY SECTION 23.54, WIS. STATUTES FORM 4100-70 REV.9-80 <br /> $ Forfeiture <br /> STATE OF WISCONSIN DEPOSIT PERMITTED/ G. B.C. No 1 6 3 $ Penalty Assess. <br /> THE UNDERSIGNED,BEING DULY SWORN AND UNDER /41( . $ , . `''- 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 CODE TWP-VILLAGE-CITY CODE ❑ WHI ❑ BLK ❑ NAT.AM. <br /> ❑ PM i v ❑ ASN ❑ HSP ❑ NON-HSP <br /> NAME LAST FIRST MI DATE OF BIRTH AGE EYES <br /> ,- ,h MO. DAY YR. HAIR <br /> STREET OR ROUTE �fy. CITY,STATE,ZIP CODE SEX ❑ M WGT. <br /> OI ❑ F HGT. <br /> DID UNLAWFULLY <br /> ON THE ABOVE STATED TIME,DATE AND LOCATION,THE DEFENDANT(DESCRIBE VIOLATION—STATE FACTS) <br /> { <br /> j__,..,7" ,,1• L <br /> 1• L,Y''' ' ;/17 ��0 <br /> in violation of section(s) of the El, -" `- '`Ordinance a,I-. / to�_3 <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$ �I SI ' v, <br /> (7 t 14 ,-s) . 7© A.M. <br /> ON 19 AT' ❑ P.M. THE COURT MAY ALSO REVOKE ALL LICENSES,CONFISCATE ALL EVIDENCE AND <br /> CITY REQUIRE RESTORATION OR RESTITUTION OF ANY ENVIRONMENTAL DAMAGE. <br />