Divorce Certificate Application Form - Wisconsin

DEPARTMENT OF HEALTH SERVICES
Division of Public Health
F-05282 (Rev. 07/2015)
STATE OF WISCONSIN
Chapter 69.21 Wis.Stats
Page 1 of 2
WISCONSIN DIVORCE CERTIFICATE APPLICATION
(for Mail or In-Person Requests)
PENALTIES: Any person who willfully and knowingly makes a false application for a divorce certificate shall be fined not more than $1,000 or imprisoned not more than 90 days,
or both, per s. 69.24(2), Wis. Stats. Any person who willfully and knowingly obtains a divorce certificate for fraudulent purposes 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 s. 69.24(1), Wis. Stats.].
I. APPLICANT INFORMATION
YOUR CURRENT NAME - First
Middle
Last
YOUR STREET ADDRESS (CANNOT be a P.O. Box address) Apt. No.
City
State
ZIP Code
City
State
ZIP Code
YOUR DAYTIME TELEPHONE NUMBER
( )
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
According to Wisconsin Statute, a CERTIFIED copy of a divorce certificate is only available to those with a “direct and tangible interest."
(See item 1 on page 2.)
Check one box which indicates YOUR RELATIONSHIP to one of the PERSONS NAMED on the divorce certificate.
A. I am one of the persons named on the divorce certificate.
B. I am a member of the immediate family of one of the persons named on the divorce certificate. CHECK ONE of the following:
Parent Brother / Sister Grandparent Child
NOTE: Grandchildren, step-parents, step-children, step-brothers/step-sisters may only obtain certified copies as categories C E.
C. I am the legal custodian or guardian of one of the persons named on the divorce certificate. (Legal proof is required.)
D. I am a representative, authorized in writing, by any of the aforementioned (categories A - C). (The written and notarized
authorization must accompany this application.)
Specify the person you represent: _______________________________________________________________________________
E. I can demonstrate that the information from the divorce certificate is necessary for the determination or protection of a personal or
property right for myself/my client/my agency. (Proof is required.)
Specify your interest: _________________________________________________________________________________________
F. None of the above. I am requesting an uncertified copy. (Copy will not be valid for legal purposes.)
PURPOSE FOR WHICH CERTIFICATE IS REQUESTED:
III. FEES
Required Search Fee (includes one copy, if found) ………………….………..…………………..……………... $ 20.00 ___20.00___
Additional copies of the same certificate 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. CANCELLATIONS NOT ACCEPTED. TOTAL ___________
Mail 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
IV. DIVORCE
INFORMATION
BIRTH NAME - First
Middle
BIRTH Last Name
BIRTH NAME - First
Middle
BIRTH Last Name
LOCATION OF DIVORCE - County COUNTY
DATE OF DIVORCE (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 divorce certificate 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.
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