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WISCONSIN LAND INFORMATION PROGRAM /741p.(1,-1,4 RECORDING FEE SUBMISSION INSTRUCTIONS: 1. Send all fees by the 16th of each month. 2. Checks should be made payable to: WI DEPARTMENT OF ADMINISTRATION • 3. Include this form with your payment. 4. if you have questions please call 608/267-2707. • T WI Land Information Program P.O. Box 7869 Madison, WI 53707-7869 L SECTION A County Name Reporting Period RnrnPt-f- (`Qtint-y January Mailing Address 741 f1 County Road K . #103 Siren, WI 54872 SECTION B • YES NO 1. Has the County Board established a Land Information Office Pursuant Wis.Stats.Sec.59.88(3)? • If so,date established? June 21, 1990 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 o:contact person for the Land Information Office,certify under the penalty of perjury that the information provided in Section B is true and correct to the best of my knowledge. /9 715-349-2599 Signature Date Phone No. SECTION C 3. Number of documents recorded and filed in the Office of Register of Deeds under Wis.Stats.Sec.59.57(1)(a)and (6a)? 500 4. 11 you have answered yes to both questions in Section B,multiply the amount on Line 3 by$2.00 and enter the total here: $ 1 , n()n no 5. If you have answered no to either questions in Section B,multiply the amount on Line 3 by$4.00 and enter the total here: $ 6. Amount submitted: $_ 1 , 000.00 CERTIFICATION I,the Register of Deeds,certify under the penalty of perjury that the information provided in Section C is true and correct to the best of my knowledge. "Y7-- -e(- ./2-/9cf- 715:-149-2183 Signature Date Phone No.