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<br />1111111111111 1llllllUIIIlInllllllllllllltllllllllllUl IIRIIII-IUlI <br />Citation Number: "AC1234567SS" <br />ADMINISTRATIVE TRAFFIC CITA.TION <br />STATE. OF MINNESOTA <br />'fCITY, COUNTY, OR STATE AGENQY NAME" <br /> <br />Drivers l.icenseNumber <br /> <br />State ICR/Event# <br /> <br /> <br /> <br />State <br /> <br />Eyes <br /> <br />Height Weight <br /> <br />Stale <br /> <br />I';tli;lk$ Model <br /> <br />Color <br /> <br /> <br />Location <br /> <br />o Speed <br /> <br />o Oliver <br /> <br /> <br />1005 <br /> <br />1004 <br /> <br />Statule/Ordinance <br />169.14 Sub. <br /> <br />o Stop Line 0 OliVer <br />S41tuteIOrdioaoce- <br />169.30 <br /> <br />In <br />Code <br /> <br />Offense <br /> <br />o Driver <br /> <br />o Owner Code <br /> <br />S41tutelOrdinance <br /> <br />Offense <br /> <br />D Driver <br /> <br />DOwner t:e <br /> <br />StatuleiOrdlflance <br /> <br />NOTE: REFER TO OPPOSITE SIDE OF CITATION FOR FURTHER INFORMATION <br /> <br /> <br />RIGHT TO CONTEST - READ CAREFULLY <br /> <br />You have the right to an administrative hearing if you wish <br />to contest this citation. Plea$e call the administrative <br />offices at "999.888~7777" within "X" days of the date of the <br />violation to schedule a hearing. If you wish to admit to <br />the administrative .offense on the opposite side of this <br />citation you must, within "X" days of it's issuance, mail <br />(or bring) the penalty set forth below together with this <br />nbtice to the If Name of Agency". <br /> <br />The State of Minnesota (MN Statute <br />has set a fine amount of $60.00 for <br />Offense. Send a check or money order, along with the <br />signed copy oUhis Administrative Citation to the <br />listed below, DO NOT send cash. <br /> <br />I understand that by paying this penalty I am admitting to <br />an Administrative Offense. I also understand that I have a <br />right to an Administrative Hearing and I waive that right. <br /> <br />Signature <br /> <br />Address <br /> <br />Zone <br /> <br />Date <br /> <br />Issuance ofawQrthless check Isa crime, and you willl:>e_ <br />subject to cMI ahd criminal penalties. In addition, a charge <br />of upto$30.00 may be assessed on all retumedchecks. <br /> <br />"Name of Agency" <br />"Street Address" <br />"CityfStateZip Code" <br />"Phone Number" <br /> <br />AP-PROVED 07 -17-09 <br />