OMB 1615-0096; Expires 04/30/2012 G-1041A, Genealogy Records Request Department of Homeland Security 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 First Name Last Name Suffix (Jr., Sr.) Apartment No. Address (Number and Street Name, P.O. Box Number or Route Number) City State/Province 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 receive it via e-mail or printed and postal mail? Part II. Zip/Postal Code Country (if other than U.S.) E-mail Postal mail Information Needed to Release a Historical Record Immigrant's Full Name (If appropriate, enter religious salutation before first name - Example: father, sister, etc.) Is the file information provided below the result of a previous Genealogy Index Search Request? Yes # No Last Name If "Yes," provide the Genealogy Index Search Request case number(s): First Name Middle Name Other names used, maiden names, aliases, or variant spellings (if any) Immigrant's Date of Birth* Check only one: Actual Day Month Full Year Immigrant's Country of Birth (include Country, Province, Town/Village, if known) 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 American LegalNet, Inc. www.FormsWorkFlow.com Part III. Identification of Requested Record(s) File Number/File Information Type of File(s) Requested Naturalization Certificate File 1906-1956 Check one or both fees Certificate Number (up to 7 digits): Date of Naturalization: Day Month Full Year C $20M* $35HC** Court City/County Number as Shown on Certificate: Non-standard C-Files (B, D, OM, OS, A, AA, OL) Alien Registration Record (AR-2), 1940-1944 Fee State Date of Issuance: Day Month Full Year Alien Registration Number (must be 7 digits): $20 M* A- or ARA-File numbered below 8 million A-File Number (must be 7 digits): $35 HC** AVisa Number (up to 7 digits): Visa File 1924-1944 Visa # Date of Entry: Month Day Registry File 1929-1944 Port of Entry: Ship (seaport arrivals only): $35 HC** Full Year Registry File Number (up to 6 digits): $35 HC** R NOTE: Total Fees Due/Attached: $ If you are a researcher providing a C-file number below C-6500000 obtained from any source other than the USCIS Genealogy Program, you may not know the format of the file (microfilm or hard copy). Therefore, you will be unable to determine the fee. In this case, submit the $20 fee. If the C-file is found in hard copy format, we will notify you to remit the additional $15. *The fee for a copy of a microfilm record (M) is $20 per request. **The fee for a copy of a textual hard copy file (HC) file is $35 per request. G-1041A (Rev. 04/30/09)Y Page 2 American LegalNet, Inc. www.FormsWorkFlow.com