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JIM DOYLE <br /> GOVERNOR <br /> �` MICHAEL L.MORGAN <br /> ' ti .. SECRETARY <br /> is <br /> ' <br /> Division of Intergovernmental Relations <br /> 101 East Wilson Street,10th Floor <br /> at <br /> ,. WISCONSIN DEPARTMENT Of Post Office Box 8944 <br /> ADMINISTRATION Meson'WI 53708-8944 <br /> Voice(608)267-3369 <br /> Fax(608)267-6917 • <br /> DOA-7108(802/2006) <br /> ss.59.72(3)&(5),and ss.59.43(2)fag)1.&(e),Wis.Stats. <br /> Instructions: <br /> Wisconsin Land Information Program 1. Send all fees by the 16m of each <br /> 9 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 /> I 4. If you have questions please call <br /> J (608)267-3369. <br /> Wisconsin Land Information Program <br /> County Recording Fee Submission <br /> Register of Deeds Name and Address: 110 Name and Address: Recording Period <br /> Jeanine Chell Jason Towne October / 2009 <br /> 7410 County Road K#103 7410 County Road K#120 <br /> Siren,WI 54872-9043 Siren,WI 54872-9043 Month / Year <br /> (NAME AND ADDRESS CORRECTION REQUESTED) <br /> Yes tis <br /> 1. Does the County Land Information Office established on 6/19/1990 by the County Board per s. 59.72(3), <br /> Wis. Stats.,continue to perform the duties specified in s.59.72(3)(a-c),Wis.Stats.? X <br /> 2. Has County used$4 of each$5 fee collected under s.59.72(5),Wis. Stats.,to develop, implement,and <br /> maintain the countywide plan for land records modernization? X <br /> 3. WiIVHas County use/d$1 of each$5 fee collected under s.59.72(5),ws.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 in questions 1-3 is true and correct to the best of my knowledge. <br /> %/ O z lop 7 715-349-2599 <br /> Signature Dat (mm/ d/ccyy) Phone Number <br /> — <br /> 4. Number of documents recorded and filed in the County Office of Register of Deeds under ss.59.43(2)(ag)1. 496 <br /> &(e),Wis.Stats. <br /> 5. If auestions 1-3 are all answered yes. multiply the amount on Line 4 by$2 and enter the total here... $ 992 <br /> 6. If questions 1,2 or 3 are answered no,multiply the amount on Line 4 by$7 and enter the total here $ <br /> $ 992.00 <br /> 7. County Check Number. In the amount of: <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 best my knowledge. <br /> JU ?./A 1,I V-1.61 //- Q -0 9 715-349-2183 <br /> RO ignature Date(mm/dd/ccyy) Phone Number <br />