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, g JIM DOYLE <br /> ,,.. GOVERNOR <br /> • MICHAEL L.MORGAN <br /> SECRETARY <br /> . Division of Intergovernmental Relations <br /> V 101 East Wilson Street,9th Floor <br /> WISCONSIN DEPARTMENT OF Post Office Box 8944 <br /> ADMINISTRATION Madison, <br /> o cel 08 26�3369944 <br /> Fax(608)M7-6917 <br /> DOA-7108(R07/2010) <br /> ss.59.72(3)&(5),and ss.59.43(2)(ag)1.&(e),Wis.Stats. <br /> Instructions: <br /> 1. Send all fees by the 16th of each <br /> Wisconsin Land Information Program month following the reporting month. <br /> PO Box 7869 2. Make check payable to: Wisconsin <br /> Madison, WI 53707-7869 Department of Administration. <br /> 3. Include this form with your payment. <br /> L__ _I 4. If you have questions please call <br /> (608)267-3369. <br /> Wisconsin Land Information Program <br /> Burnett County Recording Fee Submission <br /> Register of Deeds Name and Address: LIO Name and Address: Recording Period <br /> Jeanine Chell Jason Towne December / 2012 <br /> 7410 County Road K#103 7410 County Road K#120 Month / Year <br /> Siren,WI 54872 Siren,WI 54872 <br /> (NAME AND ADDRESS CORRECTION REQUESTED) L <br /> Yes No <br /> 1. Does the County Land Information Office established by the County Board per s.59.72(3),Wis.Stats., <br /> continue to perform the duties specified in s.59.72(3)(a-c),Wis.Stats.? X <br /> 2. Will/Has the county used$6 of each$25 fee collected under s.59.72(5),Wis.Stats.,to develop, <br /> implement,and maintain the countywide plan for land records modernization? X <br /> 3. Will/Has County use/d$2 of each$25 fee collected under s.59.72(5),Wis.Stats.,for the provision of <br /> land information on the Internet,including the county's land information records relating to housing? <br /> X <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"i •uestions 1-3 is true an ect to the best of my knowledge. <br /> 0 _- -� / _/ZDi . 715-349-2599 <br /> 4 Si nature Datm/ c Phone Number <br /> 9 YY) <br /> 4. Number of documents recorded and filed in the County Office of Register of Deeds under ss.59.43(2)(ag)1. 474 <br /> &(e),Wis.Stats. <br /> $ <br /> 5. If auestions 1-3 are all answered yes.multiply the amount on Line 4 by$2 and enter the total here... <br /> $ 948.00 <br /> 6. If questions 1,2 or 3 are answered no,multiply the amount on Line 4 by$10 and enter the total here <br /> 7. County Check Number: In the amount of: <br /> $ 948.00 <br /> Certification <br /> I,the County Register of Deeds,certify under the penalty of perjury that the information provided in questions 4-7 is true and correct to <br /> the bes : • y knowledge. <br /> 49., -���� i_0 -4:2-4/ 3 715-349-2183 <br /> RO41 ignature Date(mm/dd/ccyy) Phone Number <br />