Form At-110 - Court Report Of Conviction - Wisconsin Department Of Revenue

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COURT REPORT OF CONVICTION
WISCONSIN DEPARTMENT OF REVENUE
TO: Wisconsin Department of Revenue
Chief, Alcohol and Tobacco Enforcement Unit
Mail Stop 6-40
PO 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
day of
, 20
, one
Town
, licensed by
Village
Licensee
Municipality name
City
in the county of
, for the premises located at
Licensed Premises – Street address
, was convicted in
Licensed Premises – City, State, Zip
Municipal
Circuit
Court before
of violating
Judge / Magistrate
Section(s)
of the Wisconsin Statutes by
Nature of Charge
, the following penalty being imposed:
and / or
Fine / Forfeiture
Costs
Imprisonment
and / or
Fine / Forfeiture
Costs
Imprisonment
Period of Revocation or Suspension
Revocation
Suspension
Date From
Date To
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
Signature
Title
AT-110 (R. 4-09)

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