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
YOUR STREET ADDRESS (CANNOT be a P.O. Box address) Apt. No MAIL TO ADDRESS (if different)
YOUR DAYTIME TELEPHONE NUMBER
YOUR EMAIL ADDRESS
PHOTO ID NUMBER
TYPE OF CURRENT VALID PHOTO ID
STATE OF ISSUANCE
(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)
Brother / Sister
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.
Mail your application materials and fee to:
Be sure to include:
self-addressed, stamped, business-size envelope, and
any additional proof or authorization required
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.
Clear / Reset Form