Wisconsin Birth Certificate Application

FAX APPLICATION FOR A WISCONSIN BIRTH CERTIFICATE

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

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. Any person who willfully and knowingly obtains a birth certificate for fraudulent purposes is guilty of a Class I felony.

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.)

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.

CHECK ONE. Parent   Current Spouse   Brother / Sister   Grandparent   Child   Current Domestic Partner

C. I am the legal custodian or guardian of the person named on the birth certificate.

D. I am a representative, authorized in writing, by any of the above checkboxes.

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.

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.

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.

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

2. Additional copies of the same certificate issued at the same time as the first copy

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

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

5. Shipping

Regular Mail - No additional cost; mailed within five business days

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

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

SECTION IV – CREDIT CARD INFORMATION

We accept Visa, MasterCard, American Express, or Discover.

SECTION V – BIRTH CERTIFICATE INFORMATION

FAX APPLICATION FOR A WISCONSIN BIRTH CERTIFICATE

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” which means the following people:

• The person named on the birth certificate.

• An immediate family member defined as a parent, current spouse, brother, sister, grandparent, child, or current domestic partner of the subject of the record.

• The legal custodian or guardian of the person named on the birth certificate.

• A person authorized in writing by one of the above.

• A person who can demonstrate that the birth certificate is required to determine or to protect a personal or property right.

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.

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.

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 may take up to 5 business days plus mail time to complete.

• Applying by Fax requesting UPS Shipping: Requests 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.

Acceptable forms of identification are:

If you have questions regarding this form, please call 608-266-1373

or visit our website at http://www.dhs.wisconsin.gov/vitalrecords