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V1/VQ,V1 J.V.. VV.V% CAA 11J 49%., YVV! i\i.V1 J11]i\ V1' Ll,IiLJ Jv�� <br /> State of Wisconsin - Wisconsin Land Information Program-00A <br /> S Fin.MiamiDepartment of Administration 1011.‘ PO Box <br /> 7"1641 <br /> Division of Housing and intergovernmental Relations • / .�lM r _ _ 17 S Fairchild Stn 7"Roo <br /> DOA-7108(R07/2000) Madison,WI 53701-1641 <br /> ss.59.72(3)3(5),and ss.59.43(2)(ag)1.3(e).Wis.Stats. 111 .3{j,) Phone (6438)267-270; <br /> Fax (60 )266-6511 <br /> Wisconsin Land Information Program <br /> Recording Fee Submission <br /> Wisconsin Land Information Program <br /> PO Box 7869 <br /> Madison,WI 53707-7869 <br /> J <br /> Instructions: 1. Send all fees by the 162'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 /> 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 B is true and correct to the best of my knowledge. <br /> Signature <br /> _ilia 349-25 9 <br /> g 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). 546 <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. $ 1,092.00 <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. S <br /> 6. County Check Number (optional) <br /> 7. Amount Submitted $ 1,092.00 <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 /> ei- a -0 1 _ (715 ) 349-2183 <br /> Sign re Date(mm/dd/ccyy) Phone Number <br />