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UNIFORM ORDINANCE CITATION <br />$,'")RrM:TT COUNTY SECTION 66.119(1), WIS. STATUES <br />$ Forfeiture <br />STATE OF WISCONSIN DEPOSIT PERMITTED B.C. r,¢ $ Penalty Asses. <br />37 <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 COUNTYTOTAL <br />BELIEF, THAT ON OR ABOUT, <br />DAY OF WEEK I DATE VIOLATION TIME ❑ AM COUNTY TWP-VILLAGE-CITY <br />❑ PM <br />NAME LAST FIRST MI DATE OF BIRTH AGE <br />MO. DAY YR. <br />STREET OR ROUTE CITY, STATE, ZIP CODE SEX ❑ M <br />❑ 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) <br />and prays that he/she may be held to answer therefore. <br />of the ❑ Ordinance <br />❑ Burnett Co. ordinance adopting sec. <br />Signature of Officer -=- <br />SUBSCRIBED AND SWORN TO Before me this date 20 Title <br />Name Title Department or Agency <br />YOU ARE HEREBY NOTIFIED TO APPEAR IN THE <br />ABOVE NAMED COURT <br />A.M. THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS $ <br />j Q <br />ON 20 AT ❑ 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 />