Form F-05291 - Wisconsin Birth Certificate Application Form

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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)
Last
Last
YOUR STREET ADDRESS (CANNOT be a P.O. Box address) Apt. No MAIL TO ADDRESS (if different)
Apt. No
City
State
ZIP Code
City
State
ZIP Code
DAYTIME TELEPHONE NUMBER
EMAIL ADDRESS
(
)
PHOTO ID NUMBER
TYPE OF CURRENT VALID PHOTO ID
STATE OF ISSUANCE
EXPIRATION DATE
(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.
A.
I am a member of the immediate family of the person named on the birth certificate.
B.
Parent (My name is on the birth certificate and my parental rights have not been terminated.)
Brother / Sister
Current Spouse
Child
Maternal Grandparent
Paternal Grandparent
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.
C.
I am a representative authorized by any person in category A, B or C, including an attorney.
D.
Specify the person you represent: __________________________________________________________________________________
I can demonstrate the birth certificate is necessary for the determination or protection of a personal or property right.
E.
Specify your interest: ___________________________________________________________________________________________
None of the above. I am requesting an uncertified copy. (Copy will not be valid for identity or legal purposes.)
F.
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____
$ 0.00
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.
TOTAL ___________
$ 20.00
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
BIRTH NAME - First
Middle
Last Name as it appears on the birth certificate
BIRTHDATE
PLACE OF BIRTH - County
PLACE OF BIRTH – City, Village, or Township
SEX
(MM/DD/YYYY)
Male
Female
PARENT’S BIRTH NAME – First
Middle
Last
PARENT’S BIRTH NAME – First
Middle
Last
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.
SIGNATURE (Applicant)
Date Signed (MM/DD/YYYY)
Important: Signature and payment are required for processing.
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