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DEPARTMENT OF HEALTH AND FAMILY SERVICES STATE OF WISCONSIN (City of Milwaukee)

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DEPARTMENT OF HEALTH SERVICES
Division of Public Health
F-00124 (Rev. 11/2016)
STATE OF WISCONSIN
Wis. Stat. § 69.21
Page 1 of 2
WISCONSIN TERMINATION OF DOMESTIC PARTNERSHIP 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)
Last
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 3 on page 2.)
PHOTO ID NUMBER
STATE OF ISSUANCE
EXPIRATION DATE
II. APPLICANT’S RELATIONSHIP TO
PERSON(S) NAMED ON THE CERTIFICATE
Per Wis. Stat. § 69.20(1), a CERTIFIED copy of a termination of domestic partnership certificate is only available to those with a “direct and
tangible interest." (A–E)
CHECK ONE box which indicates YOUR RELATIONSHIP to one of the PERSONS NAMED on the termination of domestic partnership
certificate.
A. I am one of the persons named on the termination of domestic partnership certificate.
B. I am a member of the immediate family of one of the persons named on the termination of domestic partnership certificate.
Parent Child Brother / Sister
Maternal Grandparent Paternal Grandparent
C. I am the legal custodian or guardian of one of the persons named on the termination of domestic partnership certificate.
D. I am a representative authorized by any person in categories A - C, including an attorney.
Specify the person you represent: ________________________________________________________________________________
E. I can demonstrate the divorce 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, stepbrothers / stepsisters may only obtain certified copies as categories C – E.
PURPOSE FOR WHICH DOCUMENT IS REQUESTED:
III. FEES
First Copy Fee ……………………………………………………………….………………………..……………... $ 20.00 20.00
Additional copies 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. TERMINATION OF
DOMESTIC PARTNERSHIP
INFORMATION
PARTNER “A” BIRTH NAME – First
Middle
Last
PARTNER “B” BIRTH NAME – First
Middle
Last
COUNTY (where the termination of domestic partnership was filed) COUNTY
DATE OF THE OFFICIAL TERMINATION (MM/DD/YYYY)
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 termination of domestic partnership in accordance with the categories listed above.
SIGNATURE (Applicant)
Date Signed (MM/DD/YYYY)
Important: Signature and payment are required for processing.
TYPE or PRINT.
Clear / Reset Form
901 N. 9th Street, Room 103; Milwaukee WI 53233
and a self addressed, stamped, business-size envelope
WISCONSIN TERMINATION OF DOMESTIC PARTNERSHIP CERTIFICATE APPLICATION
F-00124 (Rev. 11/2016)
Page 2 of 2
1. What is the difference between a “certified” and an “uncertified” copy of a termination of domestic partnership
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. How long will it take to process my request?
APPLYING IN PERSON
APPLYING BY MAIL
3. What identification is required when applying for a termination of domestic partnership 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 termination of domestic partnership certificates are usually completed within 2 business hours
of application, if the termination of domestic partnership certificate is on file.
*Requests for uncertified copies of termination of domestic partnership certificates are not completed on the same schedule as
requests for certified copies. In-person requests for uncertified copies will be mailed and may take up to 2 weeks.
Requests for certificates may take up to 2 weeks.
For faster service log on-line at www.vitalchek.com (certified records only). Additional fees applied.
414-278-4027
www.county.milwaukee.gov.
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DEPARTMENT OF HEALTH AND FAMILY SERVICES STATE OF WISCONSIN (City of Milwaukee)

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Completed 18 July 2020

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