OMB 1615-0096; Expires 04/30/2012
G-1041A, Genealogy
Department of Homeland Security
Records Request
U.S. Citizenship and Immigration Services
START HERE - Type or print in black ink and read all instructions before completing this form.
Part I. Information About You
Full Name:
Salutation
Mr.
Mrs.
Ms.
Middle Name
Suffix (Jr., Sr.)
First Name
Last Name
Apartment No.
Address (Number and Street Name, P.O. Box Number or Route Number)
City
State/Province
Zip/Postal Code
Country (if other than U.S.)
Daytime Telephone Number: (include Area/Country Code, ext.)
E-Mail Address: (if available)
If the record(s) requested is available in electronic format, would you prefer to
E-mail
Postal mail
receive it via e-mail or printed and postal mail?
Part II.
Information Needed to Release a Historical Record
Immigrant's Full Name (If appropriate, enter religious salutation before first name - Example: father, sister, etc.)
If "Yes," provide the Genealogy Index Search
Is the file information provided below the result of a previous
Request case number(s):
Genealogy Index Search Request?
Yes
#
No
Last Name
First Name
Middle Name
Other names used, maiden names, aliases, or variant spellings (if any)
Immigrant's Date of Birth*
Immigrant's Country of Birth
Day
Month
Full Year
(include Country, Province, Town/Village, if known)
Check only one:
Actual
Estimated
* Important: If the immigrant's date of birth is less than 100 years prior to the date of this request, you must attach documentary
evidence showing that the immigrant is deceased. Do not attach original records because we will not return them.
Examples of acceptable documentary proof of death include: death certificates (uncertified copy), printed obituaries, funeral
programs or photographs of gravestones, Bible records, Social Security Death Index records (individual records only, not lists),
records relating to payment of death benefits, or other documents demonstrating the subject of the request is deceased. Do not
attach original records because we will not return them to you.
G-1041A (Rev. 04/30/09)Y