Report Of Legal Name Change Wisconsin Dhs

DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Public Health

REPORT OF LEGAL NAME CHANGE

Chapter 69.15 (4), Wis. Stats.

F-05021 (Rev. 11/09)

STATE VITAL RECORDS OFFICE USE ONLY

•

Type or print in BLACK INK.

Certificate Number __________________________________

•

Do NOT use cross-outs, erasures, write-overs, correction fluid, or correction tape.

If mistakes are made, prepare a new form.

New Name _________________________________________

If you have questions regarding this form, call (608) 267-7821.

PENALTIES: Any person who willfully and knowingly supplies any false information with the intent that the information be used in the preparation or amendment of a birth certificate is

guilty of a Class I felony [a fine of not more than $10,000 or imprisonment of not more than three years and six months, or both, per s. 69.24(1), Wis. Stats.].

•

Is the name given at birth (the one currently listed on the birth certificate) to be changed by this court order?

Yes

No

•

If “NO”, do not use this form. Do not send a name change notice to the State Vital Records Office.

•

If the legal change of name order involves a change of surname for an entire family (husband, wife and children), only the birth certificate of the husband

and children are affected and separate forms and fees are to be submitted for each person.

▪

A PERSON REQUIRED TO REGISTER AS A SEX OFFENDER MAY NOT CHANGE HIS OR HER NAME, per s. 301.45, Wis. Stats. (Class H felony).

Complete the following section about the person whose birth certificate is to be changed by this court-ordered name change. Enter the facts that are currently recorded

on the birth certificate on file in the State Vital Records Office. If the information does not match the certificate currently on file, the form will be returned for re-processing.

FIRST NAME

MIDDLE NAME

SURNAME

TITLE (e.g., Jr.)

DATE OF BIRTH (Month / Day / Year)

CITY OF BIRTH

COUNTY OF BIRTH

SEX

Male

Female

MOTHER’S FIRST NAME

MOTHER’S BIRTH SURNAME

FATHER’S FIRST NAME

FATHER’S BIRTH SURNAME

This court orders the State Vital Records Office to change the birth name recorded on the birth certificate for the person named in Part II to

FIRST NAME

MIDDLE NAME

SURNAME

TITLE (e.g., Jr.)

This court orders that the State Vital Records Office change the birth name recorded on the Wisconsin marriage certificate* for the person

named in Part II to the name listed in Part III.

*The court order must state that the Wisconsin marriage certificate is to be amended. The State Vital Records Office only changes the name

recorded on the marriage certificate of the person named in Part III if Part IV is completed.

NOTE: Do not use this form for surname changes that occur from marriage or from resuming use of a maiden name or former married

surname.

DATE OF MARRIAGE (Month / Day / Year)

COUNTY OF MARRIAGE

CITY OF MARRIAGE

NAME AT TIME OF MARRIAGE - GROOM (First / Middle / Birth Surname)

NAME AT TIME OF MARRIAGE - BRIDE (First / Middle / Birth Surname)

CURRENT NAME - GROOM (First / Middle / Surname)

CURRENT NAME - BRIDE (First / Middle / Surname)

COURT SEAL MUST

CERTIFICATION OF CLERK OF COURT OR DEPUTY

BE PRESENT

The name change recorded in Part III for the person named in Part II is granted

I hereby certify to the following:

in Branch #____________ of _______________________________County Court of the state of ___________________________.

(Name of County)

(Name of State)

The effective date of this order is _________________________________. Court Case Number ___________________________

(Month/Day/Year)

(Court Case Number is MANDATORY.)

_______________________________________________________ Date ________________________________

SIGNATURE

COURT SEAL

(Signature of Clerk of Court or Deputy)

(Month/Day/Year)

NAME (Typed or Printed) – Clerk of Court or Deputy

_____________________________________________________________

__

SEND CERTIFIED COPY OF AMENDED CERTIFICATE(S) TO: (Name)

DAYTIME TELEPHONE NUMBER

(

)

MAILING ADDRESS - Street Address

City

State

ZIP Code

VITAL RECORDS FEES

Change of birth certificate ………………………………………………….…………………………..………………………....… $ 10.00

___________

Change of marriage certificate ……………………………………………………………………………………………………...

$ 10.00

___________

One certified copy of the amended birth certificate ………………………..…………………………………………..……….… $ 20.00

___________

One certified copy of the amended marriage certificate ………………..…………………………………………...…………… $ 20.00

___________

Each additional copy of the amended birth certificate issued at the same time as the first copy ………... _________ X

$

3.00

___________

No. of Copies

Each additional copy of the amended marriage certificate issued at the same time as the first copy ….... _________ X

$

3.00

___________

No. of Copies

Make check or money order payable to: State of Wis. Vital Records

TOTAL

___________

Send this properly completed, signed, sealed form and your check or money order to:

State Vital Records Office / Legal Name Change Unit / PO Box 309 / Madison, WI 53701-0309