Fillable 976 Wisconsin Birth Certificate Application (St. Croix County Wisconsin)

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976 Wisconsin Birth Certificate Application (St. Croix County Wisconsin)

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The 976 Wisconsin Birth Certificate Application (St. Croix County Wisconsin) form is 2 pages long and contains:

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U.S.A. forms for St. Croix County Wisconsin

BROWSE ST. CROIX COUNTY WISCONSIN (WI) FORMS

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DEPARTMENT OF HEALTH SERVICES
Division of Public Health
F-05291 (Rev. 11/2016)
STATE OF WISCONSIN
Wis. Stat. § 69.21
Page 1 of 2
WISCONSIN BIRTH CERTIFICATE APPLICATION
(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)].
I. APPLICANT INFORMATION
CURRENT NAME - First
Last
MAIL TO NAME - First (if different)
YOUR STREET ADDRESS (CANNOT be a P.O. Box address) Apt. No
MAIL TO ADDRESS (if different) Apt. No
City
State
ZIP Code
City
State
ZIP Code
DAYTIME TELEPHONE NUMBER
( )
EMAIL ADDRESS
TYPE OF CURRENT VALID PHOTO ID
(See item 4 on page 2.)
PHOTO ID NUMBER
STATE OF ISSUANCE
EXPIRATION DATE
II. APPLICANT’S RELATIONSHIP TO
PERSON NAMED ON THE CERTIFICATE
Per Wis. Stat. § 69.20(1), a CERTIFIED copy of a birth certificate is only available to those with a “direct and tangible interest." (A–E)
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.
Parent (My name is on the birth certificate and my parental rights have not been terminated.)
Brother / Sister Current Spouse Child
Maternal Grandparent Paternal Grandparent 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.
D. I am a representative authorized by any person in category A, B or C, including an attorney.
Specify the person you represent: __________________________________________________________________________________
E. I can demonstrate the birth certificate is necessary for the determination or protection of a personal or property right.
Specify your interest: ___________________________________________________________________________________________
F. None of the above. I am requesting an uncertified copy. (Copy will not be valid for identity or legal purposes.)
NOTE: Grandchildren, stepparents, stepchildren and stepbrothers / stepsisters may only obtain certified copies as categories C-E.
PURPOSE FOR WHICH CERTIFICATE IS REQUESTED:
III. FEES
First Copy Fee …………………………………………….…….……………………………………………….…………... $ 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
TOTAL ___________
Submit your application materials and fee to:
Be sure to include: completed form, acceptable identification,
payment,
any additional proof or authorization required
IV. BIRTH RECORD
INFORMATION
BIRTH NAME - First
Middle
Last Name as it appears on the birth certificate
SEX
Male Female
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.
Clear / Reset Form
ST CROIX COUNTY
Register of Deeds, 1101 Carmichael Road, Hudson WI 54016
and a self addressed, stamped, business-size envelope
Make Check Payable to: Register of Deeds
WISCONSIN BIRTH CERTIFICATE APPLICATION
F-05291 (Rev. 11/2016)
Page 2 of 2
1. What is the difference between a “certified” and an “uncertified” copy of a birth certificate?
A CERTIFIED COPY:
Is printed on security paper, has a raised seal, and shows the signature of the State Registrar or Local Registrar.
Can be used for legal purposes.
Can only be obtained with a direct and tangible interest as defined in Wis. Stat. § 69.20(1).
AN UNCERTIFIED COPY:
Is printed on plain paper and marked “uncertified.”
Is for information purposes only and cannot be used for identity or legal purposes.
Contains the same information as a certified copy.
2. Limitations on access to certain birth certificates
According to Wis. Stat. ch. 69, 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?
APPLYING IN PERSON
APPLYING BY MAIL
4. What identification is required when applying for a birth certificate?
Requests for certified copies require proof of identification. Applicant’s original ID is required for in-person applications. A photocopy of
the applicant’s ID is required for mail applications.
At least one form of ID must show your name and address. Expired cards or documents will not be accepted.
Examples of acceptable forms of identification include:
One of these:
OR
Two of these:
State issued driver’s license or ID card
US or Foreign passport
Tribal or Military ID card
Bank/Earnings statement
Current, dated, signed lease
Health insurance card
US Government issued photo ID
Utility bill or traffic ticket
Vehicle registration/title
If you have questions regarding this form, please call
or visit our website at
Requests for certified copies of birth certificates are usually completed within 2 business hours of application, if the birth
certificate is on file.
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.
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.
715-386-4652
http://www.co.saint-croix.wi.us/rod.
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976 Wisconsin Birth Certificate Application (St. Croix County Wisconsin)

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Completed 26 March 2021

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