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JIM DOYLE <br /> GOVERNOR <br /> MICHAEL L MORGAN <br /> SECRETARY <br /> , Division of Intergovernmental Relations <br /> 101 East Wilson Street, 10`"Floor <br /> 944 <br /> .= WISCONSIN DEPARTMENT OF Padisonost WI 53 08- <br /> Madison,WI 53708-8944 <br /> <. ADMINISTRATION voice(608)267-3369 <br /> Fax(608)267-6917 <br /> DOA-7108(R02/2006) <br /> ss.59.72(3)&(5),and ss.59.43(2)(ag)I.&(e),Wis.Stats. <br /> Instructions: <br /> 1-- -1 1. Send all fees by the 16"'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 /> I 4. If you have questions please call <br /> (608)267-3369. <br /> Wisconsin Land Information Program <br /> County Recording Fee Submission <br /> Register of Deeds Name and Address: L1O Name and Address: Recording Period <br /> Jeanine Chell Jason Towne 2008 <br /> November / <br /> 7410 County Road K#103 7410 County Road K#120 <br /> Siren, WI 54872-9043 Siren,WI 54872-9043 Month 1 Year <br /> (NAME AND ADDRESS CORRECTION REQUESTED) <br /> Yes No <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. Will/Has County use/d$1 of each$5 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 /> provide 'n questions 1-3 is true and correct to the best of my knowledge. <br /> i Z.-/p i Zpp g'' 715-349-2599 <br /> 10 Signature <br /> Date(m /dd/ccyy) Phone Number <br /> 4. Number of documents recorded and filed in the County Office of Register of Deeds under ss.59.43(2)(ag)1. 386 <br /> & (e),Wis.Stats. $ 772.00 <br /> 5. If auestions 1-3 are all answered yes. multiply the amount on Line 4 by$2 and enter the total here... <br /> $ <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 /> $ <br /> 7. County Check Number. In the amount of <br /> 772.00 <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 /> theme. f my knowledge. <br /> %.,V11-1. -/k.; Oi' 'I _ OS 715-349-2183 <br /> RO'Signature Date(mm/dd/ccyy) Phone Number <br />