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Fillable Printable Birth Certificate Application - Wisconsin

Fillable Printable Birth Certificate Application - Wisconsin

Birth Certificate Application - Wisconsin

Birth Certificate Application - Wisconsin

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DEPARTMENT OF HEALTH SERVICES
Division of Public Health
F-05291 (Rev. 07/2015)
STATE OF WISCONSIN
Chapter 69.21 Wis.Stats.
Page 1 of 2
WISCONSIN BIRTH CERTIFICATE APPLICATION
(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 ClassI 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.].
I. APPLICANT INFORMATION
YOUR CURRENT NAME - First
Middle
Last
MAIL TO ADDRESS (if different) Apt. No
City
State
ZIP Code
City
State
ZIP Code
YOUR DAYTIME TELEPHONE NUMBER
( )
YOUR EMAIL ADDRESS
TYPE OF CURRENT VALID PHOTO ID
(See item 4 on page 2.)
PHOTOID NUMBER
STATE OF ISSUANCE
EXPIRATION DATE
II.APPLICANT’S RELATIONSHIP TO
PERSON NAMED ON THE CERTIFICATE
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 notbeen 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 guardianof 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 notarizedauthorization
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:
III.FEES
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: 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
IV.BIRTH RECORD
INFORMATION
BIRTH NAME -First
Middle
Last Name as it appears on the birth certificate
SEX
MaleFemale
BIRTHDATE (MM/DD/YYYY)
PLACE OF BIRTH - County
PLACE OF BIRTH City, Village, or Township
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.
WISCONSIN BIRTH CERTIFICATE APPLICATION
F-05291 (Rev. 07/15)
Page 2 of 2
1.What is the difference between a “certified” and an “uncertified” copy of a birth certificate?
A certified copy of a birth certificate issued by a WisconsinVital Records Office will have a raised seal, will show the signature of the State or Local
Registrar, andwill be printed on security paper. A certified copy may be required to obtain a state-issued driver’s license or identification, for travel to
foreign countries,to obtain a passport, or for benefit purposes.
State law restricts who may obtain a certified copy of a birth certificate. A certifiedcopy can only be issued to those people with a “direct and tangible
interest” (section II, categories A E) which means the following people:
The person named on the birth certificate (section II, category A).
An immediate family member, defined as current spouse, current domestic partner (Declaration of Domestic Partnership registered in the Wis. Vital
Records System under Chapter 770, Wis. Stats.), child, or parent (whose name is on the birth certificate and whose parental rights have not been
terminated), brother/sister, or grandparent of the subject of the record (section II, category B).
NOTE: Grandchildren, step-parents, and step-children can only obtain certified copies as in section II, categories C E.
The legal custodian or guardian of the person named on the birth certificate. Legal proof, e.g., a court order of custody or guardianship, is required
(section II, category C).
A person authorized in writing by one of the above. A written and notarized authorization must accompany the application and the authorization must
clearly state the relationship of the authorizing party to the subject of the record (section II, category D).
A person who can demonstrate that the birth certificate is required to determine or to protect a personal or property right (section II, category E).
Proof is required.
If you do not meet one of the above criteria, you cannot receive a certified copy of a birth certificate.
An uncertified copy will contain the same information as a certified copy but it is not acceptable for legal purposes, such as proof of identity (section II,
category F).
2.
Limitations on access to certain birth certificates
An uncertified copy will contain the same information as a certified copy but it is notacceptable for legal purposes, such as proof of identity.
According to Chapter 69, Wis. Stats., uncertified copiesof the following types of birth certificates may notbe obtained by anyone:
A child born to unmarried parents and paternity has not been established.
A child born to unmarried parents and paternity was established by court order.
Only persons with a “direct and tangible interest” (categories A E) may obtain certified copies of those types of birth certificates listed directly above.
3.
How long will it take to process my request?
Applying in Person
In-person requests for certified copies of birth certificates are usually completed within 2 business hours of application, if the birth certificate is
on file.
In-person requests for uncertified copies of birth certificates are not completed on the same schedule as requests for certified copies. In-person
requests for uncertified copies may take up to 1 month to complete.
Applying by Mail
Requests for certified copies of birth certificates may take up to 2 weeks plus mail time to complete.
Requests for uncertified copies of birth certificates are not completed on the same schedule as certified copies. Mail requests for uncertified
copies may take up to 1 month plus mail time.
4.What identification is required when applying for a birth certificate?
A photocopyof the applicant’s ID as listed below must be submitted with all mail applications. ID as listed below is required when applying in-person.
At least one form of ID must show your name and address. Expired cards or documents will not be accepted.
Acceptable forms of identification are:
One of these:
OR
Two of these:
Wisconsin driver’s license
Wisconsin ID card
Out-of-state driver’s license orID card
US government issued photo ID
Passport
Check book/bank statement
Health insurance card
Current, dated, signed lease
Utility bill or traffic ticket
Paycheck or earnings statement
If you have questions regarding this form, please call 608-266-1373
or visit our website at //www.dhs.wisconsin.gov/vitalrecords
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