Wisconsin Marriage Certificate Application
DEPARTMENT OF HEALTH SERVICES
Division of Public Health
F-05281 (Rev. 12/14) (Waukesha County Rev 12/14)
STATE OF WISCONSIN
Chapter 69.21 Wis.Stats.
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WISCONSIN MARRIAGE CERTIFICATE APPLICATION
(for Mail or In-Person Requests)
PENALTIES: Any person who willfully and knowingly makes a false application for a marriage 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 marriage 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
The information in Section I is about the person completing this application.
YOUR CURRENT NAME – First
Middle
Last
YOUR DAYTIME TELEPHONE NUMBER
( )
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
TYPE OF CURRENT VALID PHOTO ID
(See item 3 on page 2.)
PHOTO ID NUMBER
STATE OF ISSUANCE
EXPIRATION DATE
II. APPLICANT’S RELATIONSH
IP TO
PERSON(S)
NAMED
ON
THE
CERTIFICATE
According to Wisconsin Statute, a CERTIFIED copy of a marriage certificate is only available to those with a “direct and tangible interest" (categories A – E below.)
You may select to receive an uncertified copy if you just need a copy for informational purposes OR if you do not meet the criteria for categories A–E. In that
case, you may check category F below. (See item 1 on page 2 for more details.)
Check one box which indicates YOUR RELATIONSHIP to one of the PERSONS NAMED on the marriage certificate.
A. I am one of the persons named on the marriage certificate.
B. I am a member of the immediate family of one of the persons named on the marriage certificate. (Only those listed below qualify as immediate family.)
NOTE: Grandchildren, step-parents, step-children, step-brothers/ step-sisters may only obtain certified copies as section II, categories C – E.
CHECK ONE. Parent Brother / Sister Grandparent Child
C. I am the legal custodian or guardian of one of the persons named on the marriage certificate. (Legal proof is required. See items 1 and 2 on page 2.)
D. I am a representative, authorized in writing, by any of the above checkboxes (categories A - C). (The written and notarized authorization must
be attached to this application. See item 1 on page 2.)
Specify the person you represent: _____________________________________________________________________________________
E. I can demonstrate that the information from the marriage 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 identity or benefit purposes. See Items 1 and 2 on page 2.
PURPOSE FOR WHICH CERTIFICATE IS REQUESTED (Specify. This information will assist us in processing your request.)
III. FEES
FEE IS NOT REFUNDABLE IF NO RECORD IS FOUND. CANCELLATIONS ARE NOT ACCEPTED.
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
TOTAL ____________
Make check or money order payable to:
WAUKESHA COUNTY REGISTER OF DEEDS
Be sure to include (1) completed form, (2) acceptable identification, (3) any additional proof or authorization
required, (4) self-addressed, stamped business-size envelope, and (5) check or money order. Mail required items
and fee to:
Waukesha County Register of Deeds / 515 W Moreland Blvd, Room AC110 / Waukesha, WI 53188
IV.
MARRIAGE
INFORMATION
BIRTH NAME – First
Middle
BIRTH Last Name
BIRTH NAME – First
Middle
BIRTH Last Name
LOCATION OF MARRIAGE – City, Village, or Township
LOCATION OF MARRIAGE - County
DATE OF MARRIAGE (Month/Day/Year)
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
marriage certificate in accordance with the categories listed above.
SIGNATURE (Applicant)
Date Signed (Month / Day / Year)
Important: If you do not sign and date this form above , your request cannot be processed.
TYPE or PRINT.
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