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UNIFORM ORDINANCE CITATION <br /> BURNETT COUNTY SECTION 23.54, WIS. STATUTES FORM 4100-70 REV.9-80 <br /> $ Forfeiture <br /> STATE OF WISC614SIN DEPOSIT PERMITTED B.0 NQ 2 2 $ Penalty Assess. <br /> THE UNDERSIGNED,BEING DULY SWORN AND UNDER $ Court Costs <br /> OATH,COMPLAINS FOR AND ON BEHALF OF THE <br /> COUNTY OF BURNETTUPON INFORMATION AND <br /> BELIEFF,,THAT ON OR ABOUT, CIRCUIT COURT OF BURNETT COUNTY $ ' TOTAL <br /> THAT <br /> DAY OF WEEK I DATE VIOLATION TIME ❑ AM COUNTY CODE �jWP-VILpLLAGE-CITY CODE ❑ WHI ❑ BLK ❑ NAT.AM. <br /> �/ ! j.i f# ID PM l"'',I -'(". ❑ASN ❑ HSP ❑ NON-HSP <br /> NAME LAST! _,,FIRST MI DATE OF BIRTH AGE EYES <br /> r MO. DAY YR. HAIR <br /> STREET OR ROUTE CITY,STATE,ZIP CODE `` ;-.—, SEX E] M WGT. <br /> -� HGT. <br /> DID UNLAWFULLY OL <br /> ON THE ABOVE STATED TIME,DATE AND LOCATI7:THE DEFENDANT(DESCRIBE VIOLATION—STATE FACTS) <br /> in violation of section(s) +'' t- �" 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 f <br /> A.M. THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS$ <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 />