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)
YOUR STREET ADDRESS (CANNOT be a P.O. Box address) Apt. No. MAIL TO ADDRESS (if different than street address)
DAYTIME TELEPHONE NUMBER
TYPE OF CURRENT VALID PHOTO ID
PHOTO ID NUMBER
STATE OF ISSUANCE
(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.
Brother / Sister
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___
Additional copies of the same certificate issued at the same time as the first copy ___________________ X $
Number of Additional Copies
FEE IS NOT REFUNDABLE IF NO RECORD IS FOUND. CANCELLATIONS NOT ACCEPTED.
Submit your application materials and fee to: STATE VITAL RECORDS OFFICE / PO BOX 309 / MADISON, WI 53701-0309
Be sure to include:
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
BIRTH Last Name
PARTY “B” BIRTH NAME - First
BIRTH Last Name
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.
Date Signed (MM/DD/YYYY)
Important: Signature and payment are required for processing.
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