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GOVERNOR <br /> • <br /> MARC J.MAROTTA <br /> -V SECRETARY <br /> Office of Land Information Services <br /> '' WISCONSIN DEPARTMENT OF 17 South Fairchild Street, <br /> Madison,WI 53703 <br /> 4_ ADMINISTRATION Voice(608)267-2707 <br /> Fax(608)266-5519 <br /> DOA-7(O8(R09/2001) ohs/u,doa.state.wi.us <br /> http://www.doa.state.wi.us'olis <br /> ss.59.72(3)&(5),and ss.59.43(2)(ag)1.&(e),Wis.Stats <br /> Instructions: <br /> 1. Send all fees by the 16t 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 /> 4. If you have questions please call <br /> L_ (608)267-2707. <br /> Wisconsin Land Information Program <br /> Burnett County Recording Fee Submission <br /> Register of Deeds Name and Address: 110 Name and Address: Recording Period <br /> Jeanine Chell Kathy Swingle January / 2004 <br /> Register of Deeds Land Information Office <br /> 7410 Cty Rd K#103 7410 County Rd K#120 Month / Year <br /> Siren,WI 54872-9043 Siren,WI 54872 <br /> (NAME AND ADDRESS CORRECTION REQUESTED) <br /> Yes No <br /> 1. Does the Burnett County Land Information Office established on 06/21/1990 by the County Board per s. <br /> 59.72(3),Wis.Stats.,continue to perform the duties specified in s.59.72(3)(a-c),Wis.Stats.? X <br /> 2. Has Burnett County used$4 of each$5 fee collected under s.59.72(5),Wis.Stats.,to develop, <br /> implement,and maintain the countywide plan for land records modernization? X <br /> 3. Has Burnett County used$1 of each$5 fee collected under s.59.72(5),Wis.Stats.,to develop and <br /> maintain a computerized indexing of the county's land information records relating to housing, including <br /> the housing element of the county's land use plan under s.66.1001(2)(b),Stats.,in a manner that <br /> would allow for greater public access via the Internet? X <br /> Certification <br /> I,the designee or contact person for the Burnett County Land Information Office,certify under the penalty of perjury that the information <br /> provided in questions 1-3 is true and correct to the best of my knowledge. <br /> i 715-349-2599 <br /> I Sicy ature(K y Swingle) Date(mm/dd/ccyy) Phone Number <br /> 4. Number of documents recorded and filed in the Burnett County Office of Register of Deeds under ss. <br /> 59.43(2)(ag)1.&(e),Wis.Stats. 593 <br /> 5. If auestions 1-3 are all answered yes.multiply the amount on Line 4 by$2 and enter the total here... $ <br /> 6. If questions 1, 2 or 3 are answered no,multiply the amount on Line 4 by$7 and enter the total here $ 1,186.00 <br /> 7. County Check Number: In the amount of: $ 1,186.00 <br /> Certification <br /> I,the Burnett County Register of Deeds,certify under the penalty of perjury that the information provided in questions 4-7 is true and <br /> correct to the best of my knowledge. <br /> kiLja > L 0`% 715-349-2183 <br /> ROD Signature(Jeanine Chell) Date(mm/dd/ccyy) Phone Number <br />