Personally identifying information requested on this form, including credit card information and your signature, will be used to process your application and payment for the requested copies. Failure to supply this information may result in denial of your request for copies of any Wisconsin Birth Certificate.
Your credit card number and expiration date are required. The credit card number and expiration date will only be used to process payment for the fees specified in SECTION III - FEES below of this FAX Application for a Wisconsin Birth Certificate.
PENALTIES: Any person who willfully and knowingly makes a false application for a birth certificate is guilty of a Class I felony [a fine of not more than $10,000 or imprisonment of not more than three years and six months, or both, per s. 69.24(1), Wis. Stats.]
INSTRUCTIONS: ALL FAX APPLICATIONS ARE CHARGED AN EXPEDITED SERVICE FEE.
SECTION I - SHIP TO INFORMATION (Print or type.) (You must complete this section for application to be processed.)
1. FULL NAME (First , Middle , Last )
2. DAYTIME TELEPHONE NUMBER
( )
3. STREET ADDRESS or PO BOX (You must provide a street address if you are requesting shipping by UPS.)
APT. NUMBER
4. CITY, VILLAGE, or TOWNSHIP
5. STATE
6. ZIP CODE
SECTION II - APPLICANT'S RELATIONSHIP TO THE PERSON NAMED ON THE BIRTH CERTIFICATE (CHECK ONE)
This is my birth certificate.
I am a Parent (whose parental rights have not been terminated) of the person named on the birth certificate.
I am a member of the immediate family of the person named on the birth certificate. (Only those listed below qualify as immediate family.)
Check one: Spouse Child Brother / Sister Grandparent
I am the legal custodian or guardian of the person named on the birth certificate. (Legal documentation must accompany this application.)
I am a representative, authorized in writing, by the person indicated by any of the above checkboxes. (The written authorization must accompany
this application.)
Specify the person you represent:
I can demonstrate that the information from the birth certificate is necessary for the determination or protection of a personal or property right for
myself / my client / my agency.
Specify interest.
None of the above. I am requesting an uncertified copy of the birth certificate. (Copy will not be valid for identification purposes.)
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 with the categories listed above.
SECTION III - FEES FEES ARE NOT REFUNDABLE IF NO RECORD IS FOUND. CANCELLATIONS ARE NOT ACCEPTED.
Mandatory fees are already filled in. Please fill in additional fees for extra copies or UPS delivery, if applicable.
1. Search Fee (includes one copy of the birth certificate, if found) -------------------------------------------------------------------------------------------
$ 20.00
2. Additional Copies of the Certificate (issued at the same time as the first) ------------------------------------------------- X
$ 3.00
Number of Copies
3. Expedited Service Fee ------------------------------------------------------------------------------------------------------------------------------------------------
Regular Mail - No additional cost; mailed within 5 business days --------------------------------------------------------------------
UPS Next Day - $17.50 in the continental U.S.; shipped within 2 business days.-------------------------------------------------- UPS packages require a signature for delivery.
$ 0.00
$ 17.50
NOTE: If no box is checked, the copy will be sent by regular mail.
TOTAL
SECTION IV - CREDIT CARD INFORMATION We accept Visa, MasterCard, American Express, or Discover.
CREDIT CARD NUMBER EXPIRATION DATE
SIGNATURE - Credit Card Holder DATE SIGNED
SECTION V - BIRTH CERTIFICATE INFORMATION
BIRTH NAME (First, Middle, Last Name as it appears on the birth certificate)
SEX
Male Female
DATE OF BIRTH (Month / Day / Year)
PLACE OF BIRTH - City, Village, or Township
PLACE OF BIRTH - County
MOTHER' (MAIDEN) LAST NAME as it appears on the birth certificate
Mother' s First Name
Mother' s Middle Name
FATHER' LAST NAME as it appears on the birth certificate
SIGNATURE - Credit Card Holder DATE SIGNED