Fill and Sign the This Form is Only Available from the

This form is only available from the CCAP system used by the circuit courts. Blank Cell DEBTOR NAME SECONDARY ADDRESS PRIMARY ADDRESS CITY .WI .. 54321 Blank Line Blank Line Blank Line You have been ordered to pay the following: Blank Line Ct Descr. Citn. Violation Disposition Sched Type. Sched Desc. Amount 1 Charge Description Citation No. mm-dd-yyyy mm-dd-yyyy Both fine and costs Schedule Description $XXX.XX Blank Line . Total Amount Assessed: $XXX.XX . . Payments And Adjustments: $XX.XX . . Total Amount Due: $XXX.XX . Blank Line The Total Amount Due was due on December dd, yyyy. Ifpayment is not made immediately, one or more of the following enforcement actions will be taken: · arrest and commitment to the county jail. This isablank line · suspension of your driving privileges for up to two years. This isablank line · acivil judgment entered against you. This isablank line · referral to acollection agency. This isablank line · certification to the Department of Revenue for interception of your tax refund. This isablank line Blank Line Return this notice with payment to: Cty. Courthouse Secondary Address Primary Address City, WI ..54321-1234 Sample County Circuit Court -- Date: mm-dd-yyyy STATE OF WISCONSIN CIRCUIT COURT SAMPLE COUNTY For Official Use Only Case Caption Reminder Notice BLANK SPACE BLANK SPACE Date of Birth: mm-dd-yyyy Case No: 2003TR123456 This is a blank line GF-156(CCAP) 12/03 Reminder Notice Page 1of1 This form may not bemodified. Itmay besupplemented with additional material.