Wisconsin Report of Confidential Legal Name Change (F-05021C)
Official state formLegal name changeForm F-05021CFree downloadLast verified November 14, 2026
Report of a confidential court-ordered name change that the clerk of court completes and seals. It is sent with payment to the Wisconsin State Vital Records Office, which then impounds the birth record.
Who can use this form
- A person with a confidential name change order from a court under Wis. Stat. 786.36(2m).
- The clerk of court or tribal clerk completes and seals the certification part.
- After the change, the birth record is impounded and only another court order releases it, as the form says.
What to send with it
- The completed form with the clerk of court certification, signature and court seal.
- A check or money order payable to State of Wis. Vital Records.
- At least one certified copy of the updated birth record. The form says to buy it when the form is submitted, because the record is impounded afterward.
- Fees listed on the form: $10 to change the birth record, $20 for the first certified copy and $3 for each additional copy.
Where to send it
- Mail to
- State Vital Records Office ATTN: PSSU PO Box 309 Madison, WI 53701-0309
- State fee
- Change of birth record $10; first certified copy of the amended record $20; each additional copy $3. All as printed on the form.
- Typical processing
- Not provided
- Form revision
- 08/2024
- Source
- Official government page