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)].
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 3 on page 2.)
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
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:
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
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
PARTNER “A” BIRTH NAME – First
PARTNER “B” BIRTH NAME – First
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.
Important: Signature and payment are required for processing.
901 N. 9th Street, Room 103; Milwaukee WI 53233
and a self addressed, stamped, business-size envelope