STATE OF WISCONSIN
Town of ________
________ County
I, ________ ________, treasurer for the Town of ________, ________ County, Wisconsin, have during the year 20__ collected forfeitures from municipal judges of the Town of ________, as set forth below:
Dated this ______ day of ________, 20__.
[Signature of town treasurer]
STATE OF WISCONSIN,
________ County.
________ ________, being duly sworn, says that [he or she] is the treasurer of the Town of ________, ________ County, Wisconsin, and has made and signed the foregoing statement, and that the same is correct.
[Signature of town treasurer]
Subscribed and sworn to before me this ____ of ________, 20__.
[Signature and title of officer]
