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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 WISCONSIN DEPOSIT PERMITTED I B.C. No 307 $ Penalty Assess. <br /> THE UNDERSIGNED,BEING DULY SWORN AND UNDER r? I '/' $ — <br /> 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 _ 111ASN ❑ HSP 0 NON-HSP <br /> NAME LAST FIRST MI DATE OF BIRTH AGE EYES <br /> MO. DAY YR. HAIR <br /> STREET OR ROUTE CITY,STATE,ZIP CODE SEX 0 M WGT. <br /> ❑ F HGT. <br /> DID UNLAWFULLY t <br /> ON THE ABOVE STATED TIME,DATE AND LOCATION,THE DEFENDANT(DESCRIBE VIOLATION—STATE FACTS) <br /> ( -.. .r . , .. /e < , . , ,/— <br /> & <br /> i'.,G <br /> t. ' , `. _- <br /> in violation of section(s) of the 0 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 • - 'r ' <br /> Name Title '� Department or Agency% / .. <br /> YOU ARE HEREBY NOTIFIED TO APPEAR IN THE <br /> ABOVE NAMED COURT <br /> El A.M. THE MAXIMUM FORFEITURE FOR THIS VIOLATION IS$ 1 f <br /> L!,/< '' ' / 7--"1— , <br /> ON 19—AT— 0 P.M. THE COURT MAY ALSO REVOKE ALL LICENSES,CONFISCATE ALL EVIDENCE AND <br /> CITY REQUIRE RESTORATION OR RESTITUTION OF ANY ENVIRONMENTAL DAMAGE. <br /> Al <br />