Amending a birth certificate is a crucial process for those needing to correct or update the information recorded at the time of birth. The Department of Health Services in the State of Wisconsin provides a specific procedure to make such amendments through the Court Order Birth Form, as outlined by the Division of Public Health under Chapter 69, Wis. Stats. This detailed two-page document, with a strict mandate to be printed back-to-back and filled out in black ink without erasures or corrections, serves as the official request to the state’s circuit court to modify a birth record. Designed primarily for corrections such as completing an omitted part of a name or amending the spelling of a name on the birth certificate, it explicitly states its limitations by disallowing name changes or the establishment of paternity through this process. The form requires a comprehensive input of information, including the subject's current information as listed on the birth certificate, the proposed amendments, and a list of evidence supporting the petition for amendment. Following a court's approval and with the payment of the associated fees, this form facilitates the official amendment process, ensuring that the birth certificate accurately reflects the facts of birth. It underscores the importance of precision and legality in the vital records process, reflecting a meticulous approach to maintaining the integrity of such fundamental documents.
| Question | Answer |
|---|---|
| Form Name | Court Order Birth Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | court amend birth, court order to amend a wisconsin birth certificate, Wis, F-05091 |
DEPARTMENT OF HEALTH SERVICES |
STATE OF WISCONSIN |
Division of Public Health |
Chapter 69, Wis. Stats. |
Page 1 of 2 |
COURT ORDER TO AMEND A WISCONSIN BIRTH CERTIFICATE
THIS IS A
TYPE OR PRINT IN BLACK INK ONLY.
NO erasures,
When using this form to modify a name, it can only be used (1) to complete a name when part of that name has been omitted, and/or
(2) to amend the spelling of a name on a birth certificate. This form can not be used to change a name. This form can not be used to establish paternity.
STATE OF WISCONSIN
CIRCUIT COURT OF ____________________________ COUNTY, BRANCH __________________
IN RE: |
CORRECTION OF BIRTH CERTIFICATE |
|
PURSUANT TO CHAPTER 69.12, WISCONSIN STATUTES |
CONCERNING: |
______________________________________________________________________________________ |
|
(Name of the Subject of the Birth Certificate as it Currently Appears on the Birth Certificate) |
COURT CASE: |
________________________________ (Court Case Number is MANDATORY.) |
|
|
Upon the records, files, and any proceedings in the
_________________________________________________________ , who is the _____________________________
(Name of Petitioner)(Relationship of Petitioner to the Subject of the Record)
of the Subject of the Record, dated ___________________________________________, and which includes supporting
(Month / Day / Year of Petition)
evidence presented to the court as follows:
(List the evidence used to support the petition.)
1.A CURRENT CERTIFIED COPY OF THE ORIGINAL BIRTH CERTIFICATE FILED WITH THE STATE REGISTRAR
2.____________________________________________________________________________________
3.____________________________________________________________________________________
4.______________________________________________________________________________________________
IT IS ORDERED that the State Registrar amend the birth certificate of:
(NOTICE: In the following, enter all items as they read on the birth certificate PRIOR to this court order for amendment.)
__________________________________________________________, born on _______________________________________________
(Name on Birth Certificate)(Date of Birth on Birth Certificate)
to _______________________________________________, ______________________________________________
(Name of Mother)(Name of Father)
in the county of ________________________________________________ so as to correctly reflect the facts at birth as
(County of Birth Listed on Birth Certificate)
indicated on the second page of this form.
COURT ORDER TO AMEND A WISCONSIN BIRTH CERTIFICATE |
Page 2 of 2 |
TYPE OR PRINT IN BLACK INK ONLY.
Do NOT use erasures,
THE INCORRECT INFORMATION BELOW SHALL BE AMENDED TO |
THE CORRECT INFORMATION BELOW |
|||||
______________________________________________ |
________________________________________________ |
|||||
|
(Name of Subject on Certificate) |
|
(Name of Subject on Certificate) |
|
||
(First, Middle, LAST NAME IN CAPITAL LETTERS) |
|
(First, Middle, LAST NAME IN CAPITAL LETTERS) |
||||
_________________________________________________________ |
___________________________________________________________ |
|||||
|
(Spelling of Mother’s Birth Name) |
|
(Spelling of Mother’s Birth Name) |
|
||
(First, Middle, LAST NAME IN CAPITAL LETTERS) |
|
(First, Middle, LAST NAME IN CAPITAL LETTERS) |
||||
_________________________________________________________ |
___________________________________________________________ |
|||||
|
(Spelling of Father’s Birth Name) |
|
(Spelling of Father’s Birth Name) |
|
||
(First, Middle, LAST NAME IN CAPITAL LETTERS) |
|
(First, Middle, LAST NAME IN CAPITAL LETTERS) |
||||
_________________________________________________________ |
___________________________________________________________ |
|||||
|
(Other - Specify) |
|
(Other - Specify) |
|
|
|
_________________________________________________________ |
___________________________________________________________ |
|||||
|
Other - Specify) |
|
(Other - Specify) |
|
|
|
_________________________________________________________ |
___________________________________________________________ |
|||||
|
(Other - Specify) |
|
(Other - Specify) |
|
|
|
_________________________________________________________ |
__________________________________________________________ |
|||||
|
(Other - Specify) |
|
(Other - Specify) |
|
|
|
_________________________________________________________ |
__________________________________________________________ |
|||||
|
(Other - Specify) |
|
(Other - Specify) |
|
|
|
|
|
|
|
|
|
|
|
FOR COURT USE ONLY |
|
|
|
|
|
|
Dated at ________________________, Wisconsin, this _______ day of _____________________ by the court. |
|||||
|
(City, Village, or Township) |
|
(Month/Year) |
|
||
|
SIGNATURE – Circuit Court Judge ____________________________________________________________ |
|||||
COURT SEAL |
NAME (Typed or Printed) – Circuit Court Judge ____________________________________________________ |
|||||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
FEE AND MAILING INFORMATION |
|
|
|
||
Fee to amend the birth certificate ………………………………………………….… ………..…..………………………....… $ |
10.00 |
___10.00__ |
||||
One certified copy of the amended birth certificate ………………………..…………………………………………..……….… |
$ |
20.00 |
__________ |
|||
Each additional copy of the amended birth certificate issued at the same time as the first copy |
………... _________ X |
$ |
3.00 |
__________ |
||
|
|
|
No. of Copies |
|
|
|
Make check or money order payable to: State of Wis. Vital Records |
|
|
TOTAL |
__________ |
||
Send this properly completed, signed, sealed form and your check or money order to: |
|
|
|
|
||
|
State Vital Records Office / Special Records Unit / PO Box 309 / Madison, WI |
|
|
|
||
SEND CERTIFIED COPY(IES) OF THE AMENDED BIRTH CERTIFICATE TO:
NAME
DAYTIME TELEPHONE NUMBER
()
STREET ADDRESS or P.O. BOX
CITY
STATE
ZIP CODE