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JIMGOVERNOR UUYLt 4 's l;''S MARC J.MAROTTA # • SECRETARY .: ', •i: Office of Land Information Services ill WISCONSIN DEPARTMENT OF 17 South FaircStreet, Madison,WI 3703hild ADMINISTRATION Voice(608)267-2707 Fax(608)266-5519 olis(d;doa.state.wi.us DOA-7108(R09/2001) http:/www.doa.state.«i.usIolis ss.59.72(3)&(5).and ss.59.43(2)(ag)1.&1c).Wis.Stats Instructions: r 1. Send all fees by the 16`h of each Wisconsin Land Information Program month following the reporting month. PO Box 7869 2. Make check payable to: Wisconsin Madison, WI 53707-7869 Department of Administration. 3. Include this form with your payment 1 4. If you have questions please call L (608)267-2707. Wisconsin Land Information Program Burnett County Recording Fee Submission Register of Deeds Name and Address: LIO Name and Address: Recording Period ' Jeanine Chell Kathy Swingle JUNE / 2004 Register of Deeds Land Information Office • 7410 Cty Rd K#103 7410 County Rd K#120 Month / Year Siren,WI 54872-9043 Siren,WI 54872 (NAME AND ADDRESS CORRECTION REQUESTED) Yes No 1. Does the Burnett County Land Information Office established on 06/21/1990 by the County Board per s. 59.72(3),Wis.Stats.,continue to perform the duties specified in s.59.72(3)(a-c),Wis.Stats.? X 2. Has Burnett County used$4 of each$5 fee collected under s.59.72(5),Wis.Stats.,to develop, implement,and maintain the countywide plan for land records modernization? X 3. Has Burnett County used$1 of each$5 fee collected under s.59.72(5),Wis.Stats.,to develop and maintain a computerized indexing of the county's land information records relating to housing,including the housing element of the county's land use plan under s.66.1001(2)(b),Stats.,in a manner that would allow for greater public access via the Internet? X Certification I,the designee or contact person for the Burnett County Land Information Office,certify under the penalty of perjury that the information provided in questions 1-3 is true and correct to the best of my knowledge. i" a., _.. 070f 715-349-2599 L 0 S ..nature( '.thy Swingle) Date(m / odd/ccyy) Phone Number 4. Number of documents recorded and filed in the Burnett County Office of Register of Deeds under ss. 59.43(2)(ag)1.&(e),Wis.Stats. 871 5. If questions 1-3 are all answered yes.multiply the amount on Line 4 by$2 and enter the total here... $ 1,742.00 6. If questions 1, 2 or 3 are answered no,multiply the amount on Line 4 by$7 and enter the total here $ 7. County Check Number: In the amount of: $ 1,742.00 Certification I,the Burnett County Register of Deeds,certify under the penalty of perjury that the information provided in questions 4-7 is true and correct t e best of my knowledge. / `.f clap 7-1 - Q y 715-349-2183 ROD Si ature(Jeanine Chell) Date(mm/dd/ccyy) Phone Number