Fillable Form F-05282 - Wisconsin Divorce Certificate Application printable pdf download

DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Public Health

Wis. Stat. § 69.21

F-05282 (Rev. 11/2016)

Page 1 of 2

WISCONSIN DIVORCE CERTIFICATE APPLICATION

TYPE or PRINT.

(for Mail or In-Person Requests)

PENALTIES: Any person who illegally possesses any vital record with knowledge that the vital record has been illegally obtained is guilty of a Class I felony [a fine of not more

than $10,000 or imprisonment of not more than 3 years and 6 months, or both, per Wis. Stat. § 69.24(1)].

CURRENT NAME - First

MAIL TO NAME - First (if different)

Last

YOUR STREET ADDRESS (CANNOT be a P.O. Box address) Apt. No. MAIL TO ADDRESS (if different than street address)

Apt. No.

City

State

ZIP Code

City

State

ZIP Code

DAYTIME TELEPHONE NUMBER

EMAIL ADDRESS

(

)

TYPE OF CURRENT VALID PHOTO ID

PHOTO ID NUMBER

STATE OF ISSUANCE

EXPIRATION DATE

(See item 3 on page 2.)

Per Wis. Stat. § 69.20(1), a CERTIFIED copy of a divorce certificate is only available to those with a “direct and tangible interest." (A–E)

CHECK ONE box which indicates YOUR RELATIONSHIP to one of the PERSONS NAMED on the divorce certificate.

I am one of the persons named on the divorce certificate.

I am a member of the immediate family of one of the persons named on the divorce certificate.

Parent

Child

Brother / Sister

Maternal Grandparent

Paternal Grandparent

I am the legal custodian or guardian of one of the persons named on the divorce certificate.

I am a representative authorized by any person in categories A - C, including an attorney.

Specify the person you represent: _________________________________________________________________________________

I can demonstrate the divorce certificate is necessary for the determination or protection of a personal or property right.

Specify your interest ___________________________________________________________________________________________

None of the above. I am requesting an uncertified copy. (Copy will not be valid for identity or legal purposes.)

NOTE: Grandchildren, stepparents, stepchildren, stepbrothers / stepsisters may only obtain certified copies as categories C – E.

PURPOSE FOR WHICH CERTIFICATE IS REQUESTED:

First Copy Fee ……………………………………………………………….………..…………………..……………... $ 20.00 ___20.00___

$ 0.00

Additional copies of the same certificate issued at the same time as the first copy ___________________ X $

3.00 ___________

Number of Additional Copies

$ 20.00

FEE IS NOT REFUNDABLE IF NO RECORD IS FOUND. CANCELLATIONS NOT ACCEPTED.

TOTAL

___________

Submit your application materials and fee to: STATE VITAL RECORDS OFFICE / PO BOX 309 / MADISON, WI 53701-0309

Be sure to include:

completed form,

acceptable identification,

payment,

self-addressed, stamped business-size envelope, and

any additional proof or authorization required

Make check or money order payable to: STATE OF WIS. VITAL RECORDS

PARTY “A” BIRTH NAME - First

Middle

BIRTH Last Name

PARTY “B” BIRTH NAME - First

Middle

BIRTH Last Name

COUNTY

LOCATION OF DIVORCE - County

DATE OF DIVORCE (MM/DD/YYYY)

I hereby attest that the information provided on this application is correct to the best of my knowledge and belief and that I am entitled to copies of

the requested divorce certificate in accordance with the categories listed above.

SIGNATURE (Applicant)

Date Signed (MM/DD/YYYY)



Important: Signature and payment are required for processing.

Clear / Reset Form