Fillable Printable Fax Birth Certificate Application - Wisconsin

Fax Birth Certificate Application - Wisconsin

DEPARTMENT OF HEALTH SERVICES

Division of Public. Health

F-05292 (Rev. 01/15)

STATE OF WISCONSIN

Chapter 69.21(1a), (2b), Wis. Stats

Page 1 of 2

FAX APPLICATION FOR A WISCONSIN BIRTH CERTIFICATE

Personally identifying information requested on this form, including credit card information and your signature, will be used to process your application and payment for the

requested copies. Failure to supply this information may result in denial of your request for copies of any Wisconsin Birth Certificate.

Your credit card number and expiration date are required. The credit card number and expiration date will only be used to process payment for the fees specified in SECTION III

– FEES below on this FAX Application for a Wisconsin Birth Certificate.

PENALTIES: Any person who willfully 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 willfully 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.].

INSTRUCTIONS: Please complete this form and FAX to 608-255-2035. All FAX applications are charged an expedited service fee.

See Page 2 of this form for valid photo ID requirements for processing this application.

SECTION I – SHIP TO INFORMATION (Print or type.) (You must complete this section for application to be processed.)

1. NAME – First

Middle

Last

2. DAYTIME TELEPHONE NUMBER

( )

3. STREET ADDRESS or P.O. BOX (You must provide a street address if you are requesting shipping by UPS.)

APT. NUMBER

4. CITY

5. STATE

6. ZIP CODE

SECTION II – APPLICANT'S RELATIONSHIP TO THE PERSON NAMED ON THE BIRTH CERTIFICATE (CHECK ONE)

A. This is my birth certificate.

B. I am a member of the immediate family of the person named on the birth certificate. (Only those listed below qualify as immediate family.)

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

CHECK ONE. Parent (whose name is on the birth certificate and whose parental rights have not been terminated)

Current Spouse Brother / Sister Grandparent Child Current Domestic Partner (registered in the Wis. Vital Records System)

C. I am the legal custodian or guardian of the person named on the birth certificate. (Legal proof is required. See item 1 on page 2.)

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

be attached to this application. See item 1 on page 2.)

Specify the person 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 identity or benefit purposes. See Item 1 and 2 on page 2.

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 a copy of the

requested birth certificate in accordance with the categories listed above.

SIGNATURE (Applicant)



Date Signed (Month / Day / Year )

SECTION III – FEES FEES ARE NOT REFUNDABLE IF NO RECORD IS FOUND. CANCELLATIONS ARE NOT ACCEPTED.

Mandatory fees are already filled in. Fill in additional fees for extra copies or UPS delivery, if applicable.

1. Search Fee (includes one copy if found) …………………………………………………………………………………….. $ 20.00 20.00

2. Additional copies of the same certificate issued at the same time as the first copy ………__________________ X $ 3.00 __________

Number of Additional Copies

3. Expedited Service Fee ………………………...………………………………………………………………………………. $ 20.00 20.00

4. Credit Card Processing Fee …………………………………………………………………………………………………... $ 6.00 6.00

5. Shipping Regular Mail - No additional cost; mailed within five business days …………………………………… $ 0.00

UPS Next Day - $19.00 in the continental U.S.A.; shipped within two business days ……………… $ 19.00 __________

UPS packages require a signature for delivery.

NOTE: If no shipping box is checked, the copy will be sent by regular mail. TOTAL ___________

SECTION IV – CREDIT CARD INFORMATION We accept Visa, MasterCard, American Express, or Discover.

CREDIT CARD NUMBER ________________________________________________________ EXPIRATION DATE _______________________

 SIGNATURE - Credit Card Holder _______________________________________________ DATE SIGNED ___________________________

SECTION V – BIRTH CERTIFICATE INFORMATION

BIRTH NAME – First

Middle

Last Name as it appears on the birth certificate

SEX

Male Female

DATE OF BIRTH (Month / Day / Year)

PLACE OF BIRTH – City, Village, or Township

PLACE OF BIRTH – County

PARENT’S BIRTH NAME – Last

Middle

First

PARENT’S BIRTH NAME – Last

Middle

First

FAX APPLICATION FOR A WISCONSIN BIRTH CERTIFICATE

F-05292 (Rev. 01/15)

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 the State Vital Records Office will have a raised seal, will show the signature of the State Registrar, and

will 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 certified copy 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 a parent (whose name is on the birth certificate and whose parental rights have not been terminated),

current spouse, brother, sister, grandparent, child, or current domestic partner (Declaration of Domestic Partnership registered in the Wis. Vital

Records System under Chapter 770, Wis. Stats.) of the subject of the record (section II, category B).

 NOTE: Grandchildren, step-parents, step-children, step-brothers and step-sisters can only obtain certified copies as 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 be attached to this 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

According to Chapter 69, Wis. Stats., uncertified copies of the following types of birth certificates may not be 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?

Copies of birth certificates are available from the State Vital Records Office no less than 3 weeks from the date of the birth.

 Applying by Fax requesting Regular Mail Shipping

Requests for copies of birth certificates may take up to 5 business days plus mail time to complete.

 Applying by Fax requesting UPS Shipping

Requests for copies of birth certificates are usually completed and shipped within two business days.

4. What identification is required when applying for a certified or uncertified copy of a birth certificate?

A photocopy of the applicant’s ID as listed below must be submitted with all fax applications.

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:

Two of these:

 Wisconsin driver’s license

 Wisconsin ID card

 Out-of-state driver’s license or ID 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 http://www.dhs.wisconsin.gov/vitalrecords