STATE OF WISCONSIN CIRCUIT COURT MILWAUKEE COUNTY

CITY OF MILWAUKEE,

a municipal corporation,

Plaintiff,

v. Case No.

Code No. 30703

Name of Noncomplaint

Individual(s) or Entity(ies),

Defendant(s).

AFFIDAVIT OF ____________________

IN SUPPORT OF COMPLAINT FOR

ENFORCEMENT OF AN ORDER FOR

RECALL OF A FOOD PRODUCT

AND FOR INJUNCTIVE RELIEF

STATE OF WISCONSIN )

) ss.

MILWAUKEE COUNTY )

I, name, being first duly sworn upon oath, depose and state as follows:

1. I am a duly authorized officer of the City of Milwaukee Health Department (“City”) entrusted with protecting the public health under Wis. Stat. chs. 251 and 252.

2. I have been employed by the City of Milwaukee Health Department since date.

3. I have worked at the City of Milwaukee Health Department as a(n) job title for number years.

4. In my capacity as job title, I was given the responsibility and duty of serving certain orders (more fully described in the next paragraph of this affidavit) issued by the City of Milwaukee Health Commissioner to City of Milwaukee retail food establishments. I was given this responsibility and authority on date, pursuant to the agreement between the City of Milwaukee Health Department and the State of Wisconsin Department of Agriculture, dated May, 2001, which is attached hereto and incorporated herein as Exhibit 1, and §§ 17-06, 17-10 and 171-5, Milwaukee Code of Ordinances (“MCO”) and Wis. Stat. §§ 97.12 and 97.41.

5. On date, I served name of defendant(s) at address(es) of defendant(s), Health Department orders to correct emergency conditions. The order required the stores served to discontinue selling the product name of food product, remove it from their store shelves immediately, and return it to their distributor. Attached hereto and incorporated herein as Exhibit 2 are the City of Milwaukee Health Department Orders to Correct Emergency Conditions served to each of the above-referenced stores.

6. The owner(s) at all number stores were very cooperative and destroyed the name of food product in front of me. While at name(s) of establishment(s), Channel station number television cameras followed me inside the store where name of food product was located with other type of food product near the area of the store where food product was located. [Note any exceptions or noncompliance here.]

7. I verbally instructed the store owner only to remove and return the name of food product.

FURTHER AFFIANT SAYETH NAUGHT.

______________________________________

Signature

Subscribed and sworn to before me this

____ day of __________________, 20___.

____________________________________

NOTARY PUBLIC, State of Wisconsin

My Commission:______________________

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