Form F-05091 at a glance
What it is: Report of Court Order to Amend a Wisconsin Birth Record.
Who signs: Statement: "I attest that the information provided on this form is correct to the best of my knowledge and belief and that I am entitled to copies of the requested birth record." Sign in Signature - Applicant to confirm your agreement to that statement and enter the Date signed (MM/DD/YY).
This form is used when information on a birth record does not represent the actual facts in effect at the time the record was filed per Wis. Stat. § 69.12.
A filled-in Form F-05091 example: a parent reports a corrected county of birth
How to fill out Form F-05091, box by box
Part I - Current birth record information
Enter the facts as they are currently recorded on the birth record on file in the State Vital Records Office: Name, First, Middle and Last, Date of Birth (MM/DD/YYYY), County of Birth, Parent's birth name and Second parent's birth name.
Part II - Correction of information
This form should not be used to report a legal name change court order or to add or remove a parent per Wis. Stat. § 69.12(5).
Part II, Correction of information: enter the Incorrect information to be changed and the Correct information.
Part III - Certification of Clerk of Court or Deputy
Part III must be completed by the court before you return this form to the State Vital Records Office.
In Part III, the Clerk of Court or Deputy certifies that an order has been granted that the birth record be corrected to accurately reflect the facts at the time of birth, with the Court Seal (must be present), the Case number (mandatory), the Effective date (MM/DD/YYYY), the Name of judge who granted the order and the County.
The Clerk of Court or Deputy enters the Signature - Clerk of Court or Deputy, the Date signed (MM/DD/YYYY) and the Name (typed or printed) - Clerk of Court or Deputy.
More rules for Form F-05091
Type or print in black ink. No cross-outs, write-overs, erasures, or correction fluid allowed.
Contact the circuit court in the county where the birth occurred.
Gather evidence supporting the corrections along with a current certified copy of the birth record.
If the court grants the petition, return this completed, signed, and sealed form, along with the required fee.
Make check or money order payable to: State of Wis. Vital Records.
If you purchased a certified copy of the birth record from the State Vital Records Office in the last 60 days, you can enclose it with your amendment request and $10 filing fee and we will exchange it at no additional charge (checked November 8, 2026).
In Part V, enter the address where the certified copy of the amended birth record should be sent: Name, Relationship to the subject of the record, Mailing address, City, State, ZIP code, Phone number and Email address.
Common questions about Form F-05091
Where do I file it?
Mail this properly completed, signed, sealed form and your check or money order to: State Vital Records Office / ATTN: PSSU / PO Box 309 / Madison, WI 53701-0309.
Are there fees?
The fee to file the Report of Court Order to Amend a Wisconsin Birth Record is $10.00, and One long-form copy of the amended birth record or check to request a short form is 1 x $20.00 (checked November 8, 2026).
Is there a penalty?
Penalties: Per Wis. Stat. § 69.24(1), any person who willfully and knowingly supplies false information with the intent that the information be used in the preparation or amendment of a birth record is guilty of a Class I felony and shall be fined not more than $10,000 or imprisoned not more than three years and six months, or both (checked November 8, 2026).
When is this form not the right one?
This form may not be used to amend a birth record which was true and accurate at the time the record was filed.
Sources
[1] Form F-05091 (08/2026), Report of Court Order to Amend a Wisconsin Birth Record, Wisconsin Department of Health Services (the Official source link on this page).