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State of Wisconsin Wisconsin land Information Program-DOAS Fin.Mgmt. <br /> Department of Administration �� Box <br /> Division of Housing and intergovernmental Relations er 1' - 17S Fairchild St,7"1845 <br /> oor <br /> DOA-7108(807/2000) ;'1 ' Madison,WI 53701-1646 <br /> ss.59.72(3)3(5),and ss.59.43(2)(ag)1.3(a),Wis.Stats. {Irl Phone (608)267-2707 <br /> - Fax 608 266.6519 <br /> Wisconsin Land Information Program <br /> Recording Fee Submission <br /> T <br /> Wisconsin Land Information Program <br /> PO Box 7869 , <br /> Madison,WI 53707-7869 <br /> . J <br /> Instructions: 1. Send all fees by the 16°1 of each month following the reporting month. <br /> 2. Check should be made payable to: Wisconsin Department of Administration <br /> 3. Include this form with your payment. <br /> 4. If you have questions please call(608)267-2707. <br /> Section A <br /> County Name Reporting Period <br /> BURNETT COUNTY <br /> Mailing Address <br /> 7410 County Road K #103 <br /> Siren, WI. 54872 <br /> • <br /> • <br /> Section B <br /> Yes No <br /> 1. Has the County Board established a Land Informatiion Office pursuant to s.59.72(3),Wis.Stats.? X <br /> If so,date established? June 21, 1990 <br /> (mm/dd/ccyy) . <br /> 2. Has the county used the fees collected under s.59.72(5),Wis Stats.exclusively for the development, <br /> implementation,and maintentance of the county-wide plan for land records modernization? X <br /> Certification <br /> I, the designee or contact person for the Land Information Office,certify under the penalty of perjury that the Information provided in <br /> Section 8 is true and correct to the best of my knowledge. <br /> Signature (715 l 349-25 9 <br /> Date(mm/dd/ccyy) Phone Number <br /> Section C <br /> 3. Number of documents recorded and filed in the Office of Register of Deeds under ss.59.43(2)(ag)1.&(e). 555 <br /> 4. If you have answered yes to both questions in Section B,multiply the amount on Line 3 by$2.00 and <br /> enter the total here. $ 1,110.00 <br /> 5. If you have answered no to either questions in Section B.multiply the amount on Line 3 by$6.00 and <br /> enter the total here. $ <br /> 6. County Check Number (optional) <br /> 7. Amount Submitted $ 1,110.00 <br /> Certification • <br /> 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 <br /> my knowledge. • <br /> • <br /> g -0/-6 I 71s ) 349-2183 <br /> Signa re Date(mm/dd/ccyy) Phone Number <br />