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WISCONSIN LAND INFORMATION PROGRAM letreis Irk <br /> RECORDING FEE SUBMmut; <br /> ISSION •.s} 1 <br /> INSTRUCTIONS: 1. Send all fees by the 16th of each month. tt . �, •� • <br /> • <br /> 2. Checks should be made payable to: WI DEPARTMENT OF ADMINISTRATION <br /> 3. Include this form with your payment. <br /> 4. H you have questions please call 608/267-2707. <br /> P <br /> WI Land Information Program <br /> P.O. Box 7869 <br /> Madison, WI 53707-7869 <br /> SECTION A • <br /> County Name Reporting Period <br /> 12/1994 <br /> Burnett County <br /> Mailing Address <br /> 7410 County Road K , 4103 <br /> Siren, WI 54872 <br /> SECTION B <br /> YES NO <br /> 1. Has the County Board established a Land Information Office Pursuant Wis.Stats.Sec.59.88(3)? X <br /> H so,date established? <br /> 2. Has the county used the fees collected under Wis.Stats.Sec.59.88(5)exclusively for the development, <br /> implementation,and maintenance of the county-wide plan for land records modernization? g <br /> CERTIFICATION <br /> I,the designee or contact person for the Land Information ;fix,certify under the penalty of perjury that the <br /> information provided in Section B is true and correct to the best of my knowledge. <br /> �_.//__ (1 /d, i99s 715-349-2599 <br /> Sig• ture //Date Phone No. <br /> SECTION C <br /> 3. Number of documents recorded and filed in the Office cf Register of Deeds under Wis.Stats.Sec.59.57(1)(a)and (6a)? 434 <br /> 4. H you have answered yes to both questions in Section 6,multiply the amount on Line 3 by 5203 and enter the total here: $ 868 .00 <br /> 5. H you have answered no to either questions in Section B.multiply the amount on Line 3 by 54.03 and enter the total here: $ <br /> 6. Amount submitted: 5 868 .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 my knowledge. <br /> oz-) , Lyn) q j I q_5--- <br /> Signature D to Phone No. <br />