Free Letter of Non-Marriage Application, F-05260 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Public Health F-05260 (Rev. 07/08)

STATE OF WISCONSIN Chapter 69.21(1a), (2b), Wis. Stats.

LETTER OF NON-MARRIAGE APPLICATION
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 Certificate of Marriage or a Letter of Non-Marriage.
· If you require proof that a Certificate of Marriage has NOT been filed with the Wisconsin State Vital Records Office, a search for a Certificate of Marriage must be conducted for those years that you were a resident of Wisconsin from (1) the time you were 16 years of age until the present OR from (2) the date your last marriage ended in annulment, divorce, or death. · The Wisconsin State Vital Records Office provides a Letter of Non-Marriage solely as a requirement for marriage in another country. · If you had two or more names during the period to be searched, you must indicate each name used and the years that each name was used. · If no Certificate of Marriage can be found using the information from this application, you will receive a Letter of Non-Marriage as proof. · If you are submitting this application by FAX, your credit card number and expiration date are required. The credit card number and expiration date will only be used for payment for the fees specified in SECTION III ­ FEES below of this Letter of Non-Marriage Application.

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. 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 THE PERSON NAMED ON THE LETTER OF NON-MARRIAGE (CHECK ONE) I am requesting a Letter of Non-Marriage for MYSELF. I am a member of the immediate family of the person named in Section V. (Only the following qualify as immediate family.) Check one: Parent (whose parental rights have not been terminated) Brother / Sister Grandparent I am a representative of and 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 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 Letter of Non-Marriage in accordance with the categories listed above.

SIGNATURE - (Person Completing Application):
SECTION III - FEES

Date Signed:

FEES ARE NOT REFUNDABLE. CANCELLATIONS ARE NOT ACCEPTED. Mandatory fees are already filled in. Please fill in additional fees for extra copies or UPS delivery, if applicable. 20.00 __ ________

SEARCH FEE (includes one copy) Letter of Non-Marriage........................................................... .. ........................ $ 20.00 EACH ADDITIONAL COPY of the same Letter of Non-Marriage, issued at the same time as the first copy ........_________ X $ 3.00

Number of additional copies I AM MAILING IN THIS APPLICATION WITH A CHECK OR MONEY ORDER TOTAL ________ (Check payable to: State of Wisconsin Vital Records. Mail to: State of Wis. Vital Records, PO BOX 309, Madison, WI, 53701-0309) ------------- OR ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------I AM FAXING IN THIS APPLICATION WITH A CREDIT CARD NUMBER TO (608) 255-2035 (Fax fees are in addition to those listed above. Additional mandatory fax fees have already been filled in.) FAX EXPEDITED SERVICE FEE ............................................................................................................................. $ 20.00 __20.00___ FAX CREDIT CARD PROCESSING FEE ................................................................................................................. $ SHIPPING Regular Mail - No additional cost; mailed within 4 business days ......................................... .. .. .......... $ 6.00 0.00 ___6.00___ __________

UPS Next Day - $17.50 in the continental U.S.; shipped within 2 business days ............................................ $ 17.50 __________ UPS packages require a signature for delivery. 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. Complete ONLY if FAXING request.

CREDIT CARD NUMBER __________________________________________________________ EXPIRATION DATE ________________________

> SIGNATURE - Credit Card Holder _________________________________________________ DATE SIGNED ____________________________
SECTION V - BIRTH INFORMATION FOR THE PERSON NEEDING THE LETTER OF NON-MARRIAGE BIRTH NAME (First, Middle, Last Name as it appears on the birth certificate) DATE OF BIRTH (Month / Day / Year) CURRENT NAME SEX Male PLACE OF BIRTH - City & State OR City & Country (if not U.S.A.) Mother's First Name Father's First Name Female PLACE OF BIRTH - County Mother's Middle Name Father's Middle Name Enter the years you have lived in Wisconsin (ex: 1995-2005):

MOTHER'S (MAIDEN) LAST NAME as it appears on the birth certificate FATHER'S LAST NAME as it appears on the birth certificate Have You Ever Been Married? If "Yes," Date Your Last Marriage Ended (by divorce, Yes No annulment, or death):