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Fillable Printable Form G-1041A

Fillable Printable Form G-1041A

Form G-1041A

Form G-1041A

Form G-1041A 12/23/16 NPage 1 of 3
Is the file information provided below the result of a
previous Genealogy Index Search Request?
Genealogy Records Request
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form G-1041A
OMB No. 1615-0096
Expires 05/31/2019
START HERE - Type or print in black ink.
Part 1. Information About You (Requestor)
1.b.
1.c.
1.a.Family Name
(Last Name)
Given Name
(First Name)
Middle Name
Requestor's Full Name
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.
Street Number
and Name
2.b.
2.c.Apt.
Flr.
Ste.
In Care Of Name (if any)2.a.
Full Name of the Immigrant
2.b.
2.c.
2.a.Family Name
(Last Name)
Given Name
(First Name)
Middle Name
2.g.
2.i.
Province
Country
2.h.
Postal Code
ZIP Code
2.f.
State
2.e.
Part 2. Information Needed to Release a
Historical Record
YesNo
If you answered "Yes," provide the Genealogy Index Search
Request case numbers in Item Number 1.b.
Requestor's Certification
By my signature, I consent to pay all costs incurred for search,
duplication, and review of documents up to $65. (See Form
G-1041A Instructions for more information.)
Requestor's Signature
6.a.
6.b.
Date of Signature (mm/dd/yyyy)
1.a.
1.b.Genealogy Index Search Case Number
Other Names Used by the Immigrant
3.b.
3.c.
3.a.Family Name
(Last Name)
Given Name
(First Name)
Middle Name
List all other names 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.
Additional Information.
Form G-1041A 12/23/16 NPage 2 of 3
Part 3. Identification of Requested Record
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 the request form. Do not attach
original records because we will not return them. See the Who
Should Use Form G-1041A section of these Instructions for
examples of acceptable documentary proof of death.
Part 2. Information Needed to Release a
Historical Record (continued)
Naturalization Certificate File (1906 - 1956)
Date of Naturalization (mm/dd/yyyy)1.b.
Court1.c.
County
City
1.d.
1.a.Certificate Number
Number as Shown on Certificate2.a.
Date of Issuance (mm/dd/yyyy)2.b.
Non-standard C-Files (B, D, OM, OS, A, AA, OL)
Alien Registration Record (AR-2) (1940 - 1944)
Alien Registration Number (A-Number)
A or AR
3.a.
Fee
$65 (Copy Format - Microfilm)
3.b.
A-File numbered below 8 million
A
Fee$65 (Copy Format - Hard Copy)4.b.
C
Other Information for the Immigrant
Place of Birth (Include Town or Village, Province, and
Country, if known)
4.a.
Date of Birth (mm/dd/yyyy)
ActualEstimated
Is this date actual or estimated?4.b.
Town or Village5.a.
Province
5.b.
Country 5.c.
NOTE (C-file numbered C650000 and below): The fee for a
copy of a microfilm record is $65 per request.
NOTE (C-file numbered C650000 and below): The fee for a
copy of a textual hard copy file is $65 per request.
4.a.A-File Number
Visa File (1924 - 1944)
Visa Number5.a.
Date of Entry (mm/dd/yyyy)5.b.
Port-of-Entry5.c.
Ship (seaport arrivals only)
5.d.
Registry File (1929 - 1944)
$
Registry File Number
R
6.a.
Fee$65 (Copy Format - Hard Copy)5.e.
6.b.Fee
$65 (Copy Format - Hard Copy)
Total Fees Due/Attached
$65 (Microfilm)$65 (Hard Copy)
Fee (Select all appropriate boxes)1.f.
NOTE: If you are a researcher providing a C-file number
below C-650000 obtained from any source other than the
USCIS Genealogy Program, you may not know the format of
the file (microfilm or hard copy).
1.e.
Form G-1041A 12/23/16 NPage 3 of 3
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
of paper.
1.a.Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c.
Middle Name
Page NumberPart Number3.a.3.b.3.c.Item Number
3.d.
Item NumberPart NumberPage Number4.a.4.b.4.c.
4.d.
2.a.Page Number2.b.Part Number2.c.Item Number
2.d.
Item NumberPart NumberPage Number5.a.5.b.5.c.
5.d.
Item NumberPart NumberPage Number6.a.6.b.6.c.
6.d.
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