Genealogy Index Search Request Department of Homeland Security U.S. Citizenship and Immigration Services START HERE - Type or print in black ink. USCIS Form G-1041 OMB No. 1615-0096 Expires 05/31/2019 Part 1. Information About You (Requestor) Requestor's Full Name 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name 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-1041 Instructions for more information.) 6.a. Requestor's Signature 6.b. Date of Signature (mm/dd/yyyy) Requestor's Mailing Address 2.a. In Care Of Name (if any) Part 2. Immigrant's Information Full Name of the Immigrant 2.b. Street Number and Name 2.c. Apt. Ste. Flr. 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name 2.d. City or Town 2.e. State 2.g. Province 2.h. Postal Code 2.i. Country 2.f. ZIP Code 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. Additional Information. 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name Requestor's Contact Information 3. Requestor's Daytime Telephone Number 4. Requestor's Mobile Telephone Number (if any) 5. Requestor's Email Address (if any) Form G-1041 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 3 Part 2. Immigrant's Information (continued) Other Information About the Immigrant 3.a. Date of Birth (mm/dd/yyyy) 3.b. Is this date actual or estimated? Actual Estimated Place of Birth (Include Town or Village, Province, and Country, if known) 4.a. Town or Village 4.b. Province 4.c. Country 5. List additional information about residences and dates below (if any). Part 3. Other Information 1. Date of immigrant's exact arrival in the United States (mm/dd/yyyy) NOTE: If you are unsure of the date range, or it is unknown select an additional choice in Item Numbers 2.a. - 2.d. 2.a. Before 1906 6. 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 marriage, occupation): 2.b. 1906 to 1924 2.c. 1924 to 1940 2.d. After 1940 Where did the immigrant live in the United States? 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 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 of death. 3.c. City or Town 3.d. State 3.f. Postal Code 3.e. ZIP Code 3.g. Country 4.a. Date From (mm/dd/yyyy) 4.b. Date To (mm/dd/yyyy) Form G-1041 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 2 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 2.a. Page Number 2.b. Part Number 2.c. Item Number 4.a. Page Number 4.b. Part Number 4.c. Item Number 4.d. 5.a. Page Number 2.d. 5.d. 5.b. Part Number 5.c. Item Number 3.a. Page Number 3.b. Part Number 3.c. Item Number 6.a. Page Number 6.b. Part Number 6.c. Item Number 3.d. 6.d. Form G-1041 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 3