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UNIFORM ORDINANCE CITATION <br /> BURNETT COUNTY SECTION 23.54, WIS. STATUTES FORM 4100-70 REV.9-80 .. <br /> $ i - Forfeiture <br /> STATE OF WISCONSIN DEPOSIT PERMITTED B.C. NO 346 $ T Penalty Assess. <br /> JTHE UNDERSIGNED,BEING DULY SWORN AND UNDER $ 3% 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 <br /> L' © PM ❑ WHI ElBLK ElNAT.AM. <br /> ❑ ASN ❑ HSP ❑ NON-HSP <br /> NAME , - LAST FIRST MI DATE OF BIRTH AGE EYES <br /> Lot)I/1 rj0/') f { MO. DAY YR. HAIR <br /> STREET,QR ROUTE CITY, STATE,ZIP CODE WGT. <br /> } �+ f SEX .C] M <br /> J I u f.- 1Lt r`t �.. �� t-t Z 1 ❑ F HGT. <br /> DID UNLAWFULLY <br /> ON THE ABOVE STATED TIME,DATE AND LOCATION,THE DEFENDANT(DESCRIBE VIOLATION—STATE FACTS) <br /> t C" . <br /> `}4 <br /> Qi ; l ti <br /> in violation of section(s) j i 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 /> =7 <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 /> r' ❑ A.M. THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS$11 <br /> ON " 19 f'ATI�L— ❑ P.M. THE COURT MAY ALSO REVOKE ALL LICENSES,CONFISCATE ALL EVIDENCE AND <br /> CITY REQUIRE RESTORATION OR RESTITUTION OF ANY ENVIRONMENTAL DAMAGE. <br />