Free Fax Application for a Wisconsin Marriage Certificate, F-05294 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Public Health F-05294 (Rev. 01/08)

STATE OF WISCONSIN Chapter 69.21, Wis. Stats.

FAX APPLICATION FOR A WISCONSIN MARRIAGE CERTIFICATE
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 Marriage 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 Marriage Certificate.

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 nine months, or both, per s. 69.24(2), Wis. Stats.
INSTRUCTIONS: Please complete this form and FAX to 608-255-2035. ALL FAXED 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 ( ) APT. NUMBER

3. STREET ADDRESS OR P.O. BOX (You must provide a street address if you are requesting shipping by UPS.) 4. CITY, VILLAGE, OR TOWNSHIP 5. STATE 6. ZIP CODE

SECTION II - APPLICANT'S RELATIONSHIP TO ONE OF THE PERSONS NAMED ON THE MARRIAGE CERTIFICATE I am one of the persons named on the marriage certificate. I am a Parent (whose parental rights have not been terminated) of the person named on the marriage certificate

(CHECK ONE)

I am a member of the immediate family of the person named on the marriage certificate. (Only those listed below qualify as immediate family.) Spouse Child Brother / Sister Grandparent Check one: I am the legal custodian or guardian of one of the persons named on the marriage 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 marriage 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 marriage certificate. (Copy will not be valid for legal 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 marriage certificate in accordance with the categories listed above.

SIGNATURE ­ Applicant
(Person Completing Application)

Date Signed ( Month / Day / Year )

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 marriage 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

__ 20.00 __ __________

3. Expedited Service Fee ............................................................................................................ 4. Credit Card Processing Fee .................................................................................................... Regular Mail - No additional cost; mailed within 5 business days ............................... 5. Shipping UPS Next Day - $17.50 in the continental U.S.; shipped within 2 business days. ............... UPS packages require a signature for delivery. NOTE: If no box is checked, the copy will be sent by regular mail.
SECTION IV - CREDIT CARD INFORMATION We accept Visa, MasterCard, American Express, or Discover.

$ 20.00 ___20.00___ $ 6.00 ____6.00___ $ 0.00 $ 17.50 __________ TOTAL __________

CREDIT CARD NUMBER ____________________________________________________________ EXPIRATION DATE ________________________

SIGNATURE - Credit Card Holder _________________________________________________ DATE SIGNED ____________________________
SECTION V - MARRIAGE CERTIFICATE INFORMATION GROOM'S NAME (First , Middle , Last Name as it appears on the certificate) PLACE OF MARRIAGE - City, Village, or Township BRIDE'S (Maiden) NAME (First , Middle , Last Name as it appears on the certificate) DATE OF MARRIAGE (Month / Day / Year)

PLACE OF MARRIAGE - County

VITAL RECORDS OFFICE USE ONLY

Certificate Number