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STATE OF WISCONSIN RETURN COMPLETED FORM TO: <br /> DEPARTMENT OF ADMINISTRATION WISCONSIN LAND INFORMATION PROGRAM <br /> DIVISION OF INTERGOVERNMENTAL RELATIONS E:-'m% 1 PO BOX 7869,MADISON,WI 53707-7869 <br /> DOA-7108(R07/2013) VOICE(608)267-3369 <br /> SS.59.72(3)&(5),WIS STATS FAX(608)267-6917 <br /> SS.59.43(2)(AG)1.&(E),WIS.STATS. ;`r= ` TTY(608)267-9629 <br /> Register of Deeds Recording Fee Submission Report <br /> Instructions: <br /> Send all fees by the 16th of each month following the reporting month. Make check payable to: Wisconsin Department of <br /> Administration. Include this form with your payment. If you have questions please call (608)267-3369. <br /> Wisconsin Land Information Program This Return address block is placed <br /> Post Office Box 7869 for use in a standard window <br /> Madison, WI 53707-7869 envelope for your convenience. <br /> L J <br /> Wisconsin Land Information Program <br /> Burnett County Recording Fee Submission <br /> Name of Register of Deeds Recording Period: <br /> Jeanine Chell From November 1 I ToNov. 29, 2013 <br /> Street Address City Zip+4 <br /> 7410 County Road K#103 Siren 54872 <br /> Name of Land Information Officer <br /> Jason Towne <br /> Street Address City Zip +4 <br /> 7410 County Road K#120 Siren 54872 <br /> (NAME AND ADDRESS CORRECTION REQUESTED) <br /> 1. Does the County Land Information Office established by the County Board per s. 59.72(3),Wis. ®Yes 0 No <br /> Stats., continue to perform the duties specified in s. 59.72(3)(a-c), Wis. Stats.? <br /> 2. Will/Has the county used the$8 of each$30 fee collected under s. 59.72(5), Wis. Stats., to <br /> develop, implement, and maintain the countywide plan for land records modernization, including ®Yes 0 No <br /> provision of land information on the internet? <br /> Certification <br /> I,the designee or contact person for the County Land Information Office,certify under the penalty of perjury that the information <br /> provided in questions 1-2 jtrue,and correct to the best of my knowledge. <br /> (, 24/� 715-349-2599 <br /> Land Infatiori Officer Signature Date(mm/•d/cc ) Phone Number <br /> 3. Number of documents recorded and filed in the County Office of Register of Deeds under ss. <br /> 59.43(2)(ag)1. &(e), Wis. Stats. 355 <br /> 4. If questions 1-2 are both answered yes, multiply the amount on Line 3 by$2&enter the total here. $710.00 <br /> 5. If questions 1 or 2 are answered no, multiply the amount on Line 3 by$10 &enter the total here. $ <br /> 6. County Check Number: In the amount of: $710.00 <br /> Certification <br /> I,the County Register of Deeds,certify under the penalty of perjury that the information provided in questions 3-6 is true and correct <br /> to the best of my knowledge. <br /> Q, ,-, e Ntee /o9 -a 715-349-2183 <br /> Re ter of Deeds Signature Date(mm/dd/ccyy) Phone Number <br /> This document can be made available in alternate formats to individuals with disabilities upon request. <br />