Genealogy Index Search Request

• Legal Form Number: G-1041
• Section: Citizenship and Immigration Services (United States of America)
• Issuer: Citizenship and Immigration Services (United States of America)

Form G-1041 Edition 08/10/22 Page 1 of 3

Genealogy Index Search Request

Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS

Form G-1041

OMB No. 1615-0096

Expires 08/31/2025

START HERE - Type or print in black ink.►

Part 1. Information About You (Requestor)

1.b.

1.c.

1.a. Family Name

(Last Name)

Given Name

(First Name)

Middle Name

Requestor's Full Name 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.)

Requestor's Signature

Requestor's Certification

6.a.

6.b. Date of Signature (mm/dd/yyyy)

3. Requestor's Daytime Telephone Number

Requestor's Contact Information

Requestor's Mobile Telephone Number (if any)4.

Requestor's Email Address (if any)5.

Requestor's Mailing Address

City or Town2.d.

Street Number

and Name

2.b.

2.c. Apt. Flr.Ste.

In Care Of Name (if any)2.a. Full Name of the Immigrant

1.b.

1.c.

1.a. Family Name

(Last Name)

Given Name

(First Name)

Middle Name

2.g.

2.i.

Province

Country

2.h. Postal Code

ZIP Code

2.f.

State

2.e.

Part 2. Immigrant's Information

2.b.

2.c.

2.a. Family Name

(Last Name)

Given Name

(First Name)

Middle Name

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.

(USPS ZIP Code Lookup)