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UNIFORM ORDINANCE CITATION <br /> BURNETT COUNTY SECTION 66.1190), WIS. STATUTES $ i Forfeiture <br /> STATE OF WISCONSIN DEPOSIT PERMITTED B.C. 1893 $ Penalty Assess. <br /> Court Costs <br /> rTHE UNDERSIGNED,BEING DULY SWORN AND UNDER $ <br /> OATH,COMPLAINS FOR AND ON BEHALF OF THE <br /> COUNTY OF BURNETT UPON INFORMATION AND CIRCUIT COURT OF BURNETT COUNTY $ TOTAL <br /> BELIEF,THAT ON OR ABOUT, <br /> DAY OF WEEK I DATE VIOLATION TIME ❑ AM COUNTY -�-� WY <br /> C xX K 1 ti @ 9 <br /> NAME LAST FIRST MI DATE OF BIRTH AGE <br /> /C MO. DAY YR. <br /> STREET OR ROUTE f ;} j CITY,STATE,ZI CODE SEX El <br /> DID UNLAWFULLY i f', 'G /,� !;✓� x, . <br /> ON THE ABOVE STATED TIME,DATE AND LOCATION, I-{E DEFENDANT(DESCRIBE VIOLATION—STATE FACTS) <br /> G <br /> in violation of section(s) <br /> of the ❑ ` ,1 Ordinance <br /> and prays that he/she may be held to answer therefor. ❑ Burnett Co.ordinance adopting sec. <br /> Signature of Officer <br /> i <br /> f <br /> 19 Title <br /> SUBSCRIBED AND SWORN TO Before me this date <br /> Title <br /> Name Department or Agency <br /> YOU ARE HEREBY NOTIFIED TO APPEAR IN THE <br /> ABOVE NAMED COURT <br /> A.M. <br /> THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS$ <br /> ON" d� ! w7 <br /> 19"—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 />