Form G-1041a - Genealogy Records Request
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1
2
3Genealogy Records Request
USCIS
Form G-1041A
Department of Homeland Security
OMB No. 1615-0096
U.S. Citizenship and Immigration Services
Expires 05/31/2019
START HERE - Type or print in black ink.
►
Requestor's Certification
Part 1. Information About You (Requestor)
By my signature, I consent to pay all costs incurred for search,
Requestor's Full Name
duplication, and review of documents up to $65. (See Form
G-1041A Instructions for more information.)
1.a. Family Name
(Last Name)
Requestor's Signature
6.a.
1.b.
Given Name
(First Name)
1.c.
6.b. Date of Signature (mm/dd/yyyy)
Middle Name
Requestor's Mailing Address
Part 2. Information Needed to Release a
Historical Record
2.a.
In Care Of Name (if any)
1.a.
Is the file information provided below the result of a
previous Genealogy Index Search Request?
2.b.
Street Number
Yes
No
and Name
If you answered "Yes," provide the Genealogy Index Search
2.c.
Apt.
Ste.
Flr.
Request case numbers in Item Number 1.b.
2.d.
City or Town
1.b. Genealogy Index Search Case Number
2.e.
State
2.f.
ZIP Code
Full Name of the Immigrant
2.g.
Province
2.a. Family Name
2.h. Postal Code
(Last Name)
2.b.
Given Name
2.i.
Country
(First Name)
2.c.
Middle Name
Requestor's Contact Information
Other Names Used by the Immigrant
3.
Requestor's Daytime Telephone Number
List all other names immigrant has ever used, including aliases,
maiden name, and nicknames. If you need extra space to
4.
complete this section, use the space provided in Part 4.
Requestor's Mobile Telephone Number (if any)
Additional Information.
3.a. Family Name
5.
Requestor's Email Address (if any)
(Last Name)
3.b.
Given Name
(First Name)
3.c.
Middle Name
Form G-1041A 12/23/16 N
Page 1 of 3
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