Form G-1041 12/23/16 NPage 1 of 3
Genealogy Index Search Request
Department of Homeland Security
U.S. Citizenship and Immigration Services
OMB No. 1615-0096
START HERE - Type or print in black ink.►
Part 1. Information About You (Requestor)
Requestor's Full Name
By my signature, I consent to pay all costs incurred for search,
duplication, and review of documents up to $65. (See Form
G-1041 Instructions for more information.)
6.b.Date of Signature (mm/dd/yyyy)
3.Requestor's Daytime Telephone Number
Requestor's Contact Information
Requestor's Mobile Telephone Number (if any)4.
Requestor's Email Address (if any)5.
Requestor's Mailing Address
City or Town2.d.
In Care Of Name (if any)2.a.
Full Name of the Immigrant
Part 2. Immigrant's Information
Other Names Used by the Immigrant
List all other names the immigrant has ever used, including
aliases, maiden name, and nicknames. If you need extra space
to complete this section, use the space provided in Part 4.
Form G-1041 12/23/16 NPage 2 of 3
Part 3. Other Information
Date of immigrant's exact arrival in the United States
NOTE: If you are unsure of the date range, or it is unknown
select an additional choice in Item Numbers 2.a. - 2.d.
1924 to 1940
1906 to 1924
Where did the immigrant live in the United States?
Other information about the immigrant that may prove
useful in the index search (For example, name of spouse
and/or children, date of immigrant's death, military
service, date of naturalization, date of female immigrant's
Important: If the immigrant's date of birth is less than 100
years prior to the date of this request, you must attach
documentary proof of death to this request. Do not attach
original records because we will not return them. See the What
Information Is Required to Begin an Index Search section of
the Instructions for examples of acceptable documentary proof
City or Town3.c.
Date From (mm/dd/yyyy)
List additional information about residences and dates
below (if any).
Date To (mm/dd/yyyy)
Other Information About the Immigrant
Place of Birth (Include Town or Village, Province, and
Country, if known)
Date of Birth (mm/dd/yyyy)
Is this date actual or estimated?3.b.
Town or Village4.a.
Part 2. Immigrant's Information (continued)
Form G-1041 12/23/16 NPage 3 of 3
Item NumberPart NumberPage Number4.a.4.b.4.c.
2.a.Page Number2.b.Part Number2.c.Item Number
Page NumberPart Number3.a.3.b.3.c.Item Number
Part 4. Additional Information
If you need extra space to provide any additional information
within this request, use the space below. If you need more
space than what is provided, you may make copies of this page
to complete and file with your request or attach a separate sheet
1.b. Given Name
Item NumberPart NumberPage Number5.a.5.b.5.c.
Item NumberPart NumberPage Number6.a.6.b.6.c.