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Get WI F-05291 2016-2024

APPLICANT S RELATIONSHIP TO PERSON NAMED ON THE CERTIFICATE 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. 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 Wisconsin Vital Records Office will have a raised seal will show the signature of the State or Local Registrar and will be printed on security paper. 21 Wis. Stats. 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. Copies may take up to 1 month plus mail time. 4. What identification is required when applying for a birth certificate A photocopy of 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 Wisconsin driver s license Wisconsin ID card Out-of-state driver s license or ID card Two of these 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. CANCELLATION REQUESTS ARE NOT ACCEPTED. TOTAL 20. 00 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 SEX Male BIRTHDATE MM/DD/YYYY Female Last Name as it appears on the birth certificate PLACE OF BIRTH - County q 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. DEPARTMENT OF HEALTH SERVICES Division of Public Health F-05291 Rev* 07/2015 STATE OF WISCONSIN Chapter 69. 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. I. APPLICANT INFORMATION YOUR CURRENT NAME - First Middle Last YOUR STREET ADDRESS CANNOT be a P. O. Box address Apt. No MAIL TO ADDRESS if different City State ZIP Code YOUR DAYTIME TELEPHONE NUMBER Apt.

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