The following statutes affect this form: s. 125.12 (2) (ag), Wis. stats. To the Town Board of the Town of ________, ________ County, Wisconsin:
The undersigned, ________ ________, a resident of the Town of ________, ________ County, Wisconsin, makes complaint against ________ ________, of the town, who is licensed to sell [describe kind of license] on the following described premises [describe them] in the town, and alleges [that the licensee has violated ch. 125, Wis. stats., or a regulation adopted under s. 125.10, Wis. stats., (specify violation) or that the licensee keeps or maintains a disorderly or riotous, indecent or improper house or that the licensee has sold or given away alcohol beverages to known habitual drunkards or that the licensee does not possess the qualifications required under ch. 125, Wis. stats., to hold the license]. [State fully the facts relied upon to sustain complaint.] Dated this ______ day of ________, 20__.
STATE OF WISCONSIN
________ County
________ ________, being duly sworn, says that the foregoing complaint is true.
[Signature]
Subscribed and sworn to before me, this ____ of ________, 20__.
[Signature and title of officer]
*[Security for costs (Optional) We hereby undertake to pay all costs of the proceedings against ________ ________, upon the above complaint, if the same is, upon hearing, found to be malicious and made without probable cause.
Dated this ______ day of ________, 20__.
[Signatures of sureties]
