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'.INSTRUCTIONS: 1. Send all fees by the 16th of each month. �~"1 .+F -. moi= », • 2. Checks should be made payable to: WI DEPARTMENT OF ADMINISTRATION `i .. 3. include this form with your payment. 4. If fou have questions please call 608/267-2707. IT . f WI Land Information Program P.O. Box 7869 Madison, WI 53707-7869 • SECTION A County Name Ru � r �,� rnQnty November, 1994 Mailing Address ' 7410 county Road Kr 4103 - Siren, WI 54872 Reporting Period SECTION B _ 1. Has the County Board established a Land Information Office Pursuant Wis. Stats.Sec.59.88(3)? YES NO X If so,date established? 2. Has the county used the fees collected under Wis.Stats.Sec.59.88(5)exclusively for the development, implementation,and maintenance of the county-wide plan for land records modernization? X - CERTIFICATION I,the designee or contact person for the Land Information Office,certify under the penalty of perjury thatthe information provided in Section B is true 2nd correct to the best of my knowledge. ,tom e G, —" I� .a 9 • Signature �: 715-.349-2599 Date Phone No. SECTION C I. Number of documents recorded and filed in the Office of Register of Deeds under Wis.Stats.Sec.59.57(1)(a)and(6a)? 529 . tl you have answered yes to both questions in Section B,multiply the amount on Line 3 by$200 and enter the total here: 1 ,058 . 00 tl you have answered no to either questions in Section B,multiply the amount on Line 3 by$4.03 and enter the total here: $- Amount submitted: 5 1 ,0 58 . 00 ERTIFICATION the Register of Deeds, certify under the penalty of perjury that the information provided in Section C is the and correct to the best of my knowledge. ,-- er2/..,..,____„ ,,cam . I / --_7,-,/ --n______,,„,, ________, ?nature - -2 Date Phone No. . �;y: ''.N, F.