Form F-05291 "Wisconsin Birth Certificate Application (For Mail or in-Person Requests)" - Wisconsin

What Is Form F-05291?

This is a legal form that was released by the Wisconsin Department of Health Services - a government authority operating within Wisconsin. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2016;
  • The latest edition provided by the Wisconsin Department of Health Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form F-05291 by clicking the link below or browse more documents and templates provided by the Wisconsin Department of Health Services.

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Download Form F-05291 "Wisconsin Birth Certificate Application (For Mail or in-Person Requests)" - Wisconsin

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
Wis. Stat. § 69.21
F-05291 (Rev. 11/2016)
Page 1 of 2
WISCONSIN BIRTH CERTIFICATE APPLICATION
TYPE or PRINT.
(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)].
CURRENT NAME - First
MAIL TO NAME - First (if different)
Last
Last
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
(
)
PHOTO ID NUMBER
TYPE OF CURRENT VALID PHOTO ID
STATE OF ISSUANCE
EXPIRATION DATE
(See item 4 on page 2.)
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.
I am the PERSON NAMED on the birth certificate.
A.
I am a member of the immediate family of the person named on the birth certificate.
B.
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)
I am the legal custodian or guardian of the person named on the birth certificate.
C.
I am a representative authorized by any person in category A, B or C, including an attorney.
D.
Specify the person you represent: __________________________________________________________________________________
I can demonstrate the birth certificate is necessary for the determination or protection of a personal or property right.
E.
Specify your interest: ___________________________________________________________________________________________
None of the above. I am requesting an uncertified copy. (Copy will not be valid for identity or legal purposes.)
F.
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____
$ 0.00
Each additional copy of the same record, issued at the same time as the first copy
___________________ X $ 3.00 ___________
Number of additional copies
FEE IS NOT REFUNDABLE IF NO RECORD IS FOUND. CANCELLATION REQUESTS ARE NOT ACCEPTED.
TOTAL ___________
$ 20.00
Submit your application materials and fee to: STATE VITAL RECORDS OFFICE / PO BOX 309 / MADISON, WI 53701-0309
Be sure to include:
completed form,
acceptable identification,
payment,
self-addressed, stamped, business-size envelope, and
any additional proof or authorization required
Make check or money order payable to: STATE OF WIS. VITAL RECORDS
BIRTH NAME - First
Middle
Last Name as it appears on the birth certificate
BIRTHDATE
PLACE OF BIRTH - County
PLACE OF BIRTH – City, Village, or Township
SEX
(MM/DD/YYYY)
Male
Female
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
DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
Wis. Stat. § 69.21
F-05291 (Rev. 11/2016)
Page 1 of 2
WISCONSIN BIRTH CERTIFICATE APPLICATION
TYPE or PRINT.
(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)].
CURRENT NAME - First
MAIL TO NAME - First (if different)
Last
Last
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
(
)
PHOTO ID NUMBER
TYPE OF CURRENT VALID PHOTO ID
STATE OF ISSUANCE
EXPIRATION DATE
(See item 4 on page 2.)
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.
I am the PERSON NAMED on the birth certificate.
A.
I am a member of the immediate family of the person named on the birth certificate.
B.
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)
I am the legal custodian or guardian of the person named on the birth certificate.
C.
I am a representative authorized by any person in category A, B or C, including an attorney.
D.
Specify the person you represent: __________________________________________________________________________________
I can demonstrate the birth certificate is necessary for the determination or protection of a personal or property right.
E.
Specify your interest: ___________________________________________________________________________________________
None of the above. I am requesting an uncertified copy. (Copy will not be valid for identity or legal purposes.)
F.
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____
$ 0.00
Each additional copy of the same record, issued at the same time as the first copy
___________________ X $ 3.00 ___________
Number of additional copies
FEE IS NOT REFUNDABLE IF NO RECORD IS FOUND. CANCELLATION REQUESTS ARE NOT ACCEPTED.
TOTAL ___________
$ 20.00
Submit your application materials and fee to: STATE VITAL RECORDS OFFICE / PO BOX 309 / MADISON, WI 53701-0309
Be sure to include:
completed form,
acceptable identification,
payment,
self-addressed, stamped, business-size envelope, and
any additional proof or authorization required
Make check or money order payable to: STATE OF WIS. VITAL RECORDS
BIRTH NAME - First
Middle
Last Name as it appears on the birth certificate
BIRTHDATE
PLACE OF BIRTH - County
PLACE OF BIRTH – City, Village, or Township
SEX
(MM/DD/YYYY)
Male
Female
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
WISCONSIN BIRTH CERTIFICATE APPLICATION
Page 2 of 2
F-05291 (Rev. 11/2016)
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
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.
APPLYING BY MAIL
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.
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:
 Bank/Earnings statement
State issued driver’s license or ID card
US Government issued photo ID
 Current, dated, signed lease
 Health insurance card
US or Foreign passport
 Utility bill or traffic ticket
Tribal or Military ID card
 Vehicle registration/title
If you have questions regarding this form, please call 608-266-1373
or visit our website at http://www.dhs.wisconsin.gov/vitalrecords
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