DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
Wis. Stat. § 69.21
F-05291 (Rev. 11/2016)
Page 1 of 2
WISCONSIN BIRTH 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)
DAYTIME TELEPHONE NUMBER
PHOTO ID NUMBER
TYPE OF CURRENT VALID PHOTO ID
STATE OF ISSUANCE
(See item 4 on page 2.)
Per Wis. Stat. § 69.20(1), a CERTIFIED copy of a birth certificate is only available to those with a “direct and tangible interest." (A–E)
CHECK ONE box which indicates YOUR RELATIONSHIP to the PERSON NAMED on the birth certificate.
I am the PERSON NAMED on the birth certificate.
I am a member of the immediate family of the person named on the birth certificate.
Parent (My name is on the birth certificate and my parental rights have not been terminated.)
Brother / Sister
Current Domestic Partner (registered in the Wis. Vital Records System)
I am the legal custodian or guardian of the person named on the birth certificate.
I am a representative authorized by any person in category A, B or C, including an attorney.
Specify the person you represent: __________________________________________________________________________________
I can demonstrate the birth 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 and stepbrothers / stepsisters may only obtain certified copies as categories C-E.
PURPOSE FOR WHICH CERTIFICATE IS REQUESTED:
First Copy Fee …………………………………………….…….……………………………………………….…………... $ 20.00 __20.00____
Each additional copy of the same record, issued at the same time as the first copy
___________________ X $ 3.00 ___________
Number of additional copies
FEE IS NOT REFUNDABLE IF NO RECORD IS FOUND. CANCELLATION REQUESTS ARE 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
BIRTH NAME - First
Last Name as it appears on the birth certificate
PLACE OF BIRTH - County
PLACE OF BIRTH – City, Village, or Township
PARENT’S BIRTH NAME – First
PARENT’S BIRTH NAME – First
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 birth certificate in accordance to the categories listed above.
Date Signed (MM/DD/YYYY)
Important: Signature and payment are required for processing.
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