Genealogy Records Request Department of Homeland Security U.S. Citizenship and Immigration Services START HERE - Type or print in black ink. USCIS Form G-1041A 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-1041A 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) 2.b. Street Number and Name 2.c. Apt. Ste. Flr. Part 2. Information Needed to Release a Historical Record 1.a. Is the file information provided below the result of a previous Genealogy Index Search Request? Yes No If you answered "Yes," provide the Genealogy Index Search Request case numbers in Item Number 1.b. 1.b. Genealogy Index Search Case Number 2.d. City or Town 2.e. State 2.g. Province 2.h. Postal Code 2.i. Country 2.f. ZIP Code Full Name of the Immigrant 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 Other Names Used by the Immigrant 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. 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name 4. Requestor's Mobile Telephone Number (if any) 5. Requestor's Email Address (if any) Form G-1041A 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 3 Part 2. Information Needed to Release a Historical Record (continued) Other Information for the Immigrant 4.a. Date of Birth (mm/dd/yyyy) 4.b. Is this date actual or estimated? Actual Estimated Place of Birth (Include Town or Village, Province, and Country, if known) 5.a. Town or Village 5.b. Province 5.c. Country 1.f. Fee (Select all appropriate boxes) $65 (Microfilm) $65 (Hard Copy) Non-standard C-Files (B, D, OM, OS, A, AA, OL) 2.a. Number as Shown on Certificate 2.b. Date of Issuance (mm/dd/yyyy) Alien Registration Record (AR-2) (1940 - 1944) 3.a. Alien Registration Number (A-Number) A or AR 3.b. Fee $65 (Copy Format - Microfilm) 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. A-File numbered below 8 million 4.a. A-File Number 4.b. Fee A $65 (Copy Format - Hard Copy) Visa File (1924 - 1944) 5.a. Visa Number 5.b. Date of Entry (mm/dd/yyyy) 5.c. Port-of-Entry Part 3. Identification of Requested Record 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. 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). 5.d. Ship (seaport arrivals only) 5.e. Fee $65 (Copy Format - Hard Copy) Naturalization Certificate File (1906 - 1956) 1.a. Certificate Number Registry File (1929 - 1944) 6.a. Registry File Number 6.b. Fee R C 1.b. Date of Naturalization (mm/dd/yyyy) 1.c. Court $65 (Copy Format - Hard Copy) Total Fees Due/Attached $ 1.d. City 1.e. County Form G-1041A 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-1041A 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 3