Court Report Of Conviction {AT-110}

WISCONSIN DEPARTMENT OF REVENUE COURT REPORT OF CONVICTION TO: Chief, Alcohol and Tobacco Enforcement Section Mail Stop 6-40 P.O. Box 8933 Madison, WI 53708-8933 In accordance with the provisions of Section 125.13 of the Wisconsin Statutes, YOU ARE HEREBY NOTIFIED that on the one in the county of (Address of Licensed Premises) (Licensee) day of , licensed by (Town-Village-City) , 20 , , , for the premises located at , was convicted in Municipal Circuit Section(s) Court before (Judge/Magistrate) of violating (Nature of Charge) of the Wisconsin Statutes by , the following penalty being imposed: and/or and/or (Fine/Forfeiture) (Costs) (Imprisonment) (Fine/Forfeiture) (Costs) (Imprisonment) Revocation Suspension Period of Revocation or Suspension: ­ (From Date) (To Date) Disposition of Evidence (If action was initiated by Wisconsin Department of Revenue) The foregoing is a report of the records on file in this Court, in witness whereof I have set my hand this day of , 20 . Signed Title AT-110 (R. 01-02) American LegalNet, Inc. www.FormsWorkflow.com