Form F-05291 - Wisconsin Birth Certificate Application

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DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Public Health

Chapter 69.21 Wis.Stats.

F-05291 (Rev. 07/15)

Page 1 of 2

WISCONSIN BIRTH CERTIFICATE APPLICATION

TYPE or PRINT.

(for Mail or In-Person Requests)

PENALTIES: Any person who wilfully and knowingly makes a false application for a birth certificate 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 s. 69.24(1)]. Any person who wilfully and knowingly obtains a birth certificate for fraudulent purposes 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 s. 69.24(1), Wis. Stats.].

YOUR CURRENT NAME - First

Middle

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

YOUR DAYTIME TELEPHONE NUMBER

YOUR EMAIL ADDRESS

(

)

PHOTO ID NUMBER

TYPE OF CURRENT VALID PHOTO ID

STATE OF ISSUANCE

EXPIRATION DATE

(See item 4 on page 2.)

According to Wisconsin Statute, a CERTIFIED copy of a birth certificate is only available to those with a “direct and tangible interest."

(See item 1 on page 2.)

Check one box which indicates YOUR RELATIONSHIP to the PERSON NAMED on the birth certificate.

A. I am the PERSON NAMED on the birth certificate.

B. I am a member of the immediate family of the PERSON NAMED on the birth certificate. CHECK ONE of the following:

Parent (My name is on the birth certificate and my parental rights have not been terminated)

Current Spouse

Brother / Sister

Grandparent

Child

Current Domestic Partner (registered in the Wis. Vital Records System)

NOTE: Grandchildren, step-parents, step-children and step-brothers/step-sisters may only obtain certified copies as categories C – E.

C. I am the legal custodian or guardian of the PERSON NAMED on the birth certificate. (Legal proof is required.)

D. I am a representative authorized, in writing, by any of the aforementioned (categories A - C). (The written and notarized authorization

must accompany this application.)

Specify whom you represent. _____________________________________________________________________________________

E. I can demonstrate that the information from the birth certificate is necessary for the determination or protection of a personal or

property right for myself/my client/my agency. (Proof is required.)

Specify your interest. ___________________________________________________________________________________________

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

PURPOSE FOR WHICH CERTIFICATE IS REQUESTED:

Required Search Fee (includes one copy, if found) .…….……………………………………………….…………... $ 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.

TOTAL ___________

Mail your application materials and fee to:

Be sure to include:

completed form,

acceptable identification,

payment,

self-addressed, stamped, business-size envelope, and

any additional proof or authorization required

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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