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)].
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
DAYTIME TELEPHONE NUMBER
TYPE OF CURRENT VALID PHOTO ID
(See item 4 on page 2.)
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:
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
Submit your application materials and fee to:
Be sure to include: completed form, acceptable identification,
any additional proof or authorization required
IV. BIRTH RECORD
Last Name as it appears on the birth certificate
PLACE OF BIRTH – City, Village, or Township
PARENT’S BIRTH NAME – First
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.
Important: Signature and payment are required for processing.
Milwaukee County Register of Deeds, 901 N. 9th St. - Rm. 103, Milwaukee, WI 53233
and a self addressed, stamped, business-size envelope
***Payment must be a money order or cashier's check. No personal checks.***