DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
Wis. Stat. § 69.21
F-05281 (Rev. 11/2016)
Page 1 of 2
WISCONSIN MARRIAGE 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 than street address)
Apt. No.
City
State
ZIP Code
City
State
ZIP Code
DAYTIME TELEPHONE NUMBER
EMAIL ADDRESS
(
)
TYPE OF CURRENT VALID PHOTO ID
PHOTO ID NUMBER
STATE OF ISSUANCE
EXPIRATION DATE
(See item 3 on page 2.)
Per Wis. Stat. § 69.20(1), a CERTIFIED copy of a marriage certificate is only available to those with a “direct and tangible interest." (A–E)
CHECK ONE box which indicates YOUR RELATIONSHIP to one of the PERSONS NAMED on the marriage certificate.
I am one of the persons named on the marriage certificate.
A.
I am a member of the immediate family of one of the persons named on the marriage certificate.
B.
Parent
Child
Brother / Sister
Maternal Grandparent
Paternal Grandparent
I am the legal custodian or guardian of one of the persons named on the marriage certificate.
C.
I am a representative authorized by any person in categories A - C, including an attorney.
D.
Specify the person you represent: ____________________________________________________________________________________
I can demonstrate the marriage 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, 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
Additional copies of the same certificate issued at the same time as the first copy …...…__________________ X $ 3.00 ___________
Number of Additional Copies
$ 20.00
FEE IS NOT REFUNDABLE IF NO RECORD IS FOUND. CANCELLATIONS ARE NOT ACCEPTED.
TOTAL
____________
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
GROOM / SPOUSE 1 BIRTH NAME – First
Middle
BIRTH Last Name
BRIDE / SPOUSE 2 BIRTH NAME – First
Middle
BIRTH Last Name
LOCATION OF MARRIAGE – City, Village, or Township
DATE OF MARRIAGE (MM/DD/YYYY)
LOCATION OF MARRIAGE - County
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 marriage certificate in accordance with the categories listed above.
SIGNATURE (Applicant)
Date Signed (MM/DD/YYYY)
Important: Signature and payment are required for processing.
Clear / Reset Form