Genealogy Records Request

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

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

Is the file information provided below the result of a

previous Genealogy Index Search Request?

Genealogy Records Request

Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS

Form G-1041A

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

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

2.b.

2.c.

2.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. Information Needed to Release a

Historical Record

Yes No

If you answered "Yes," provide the Genealogy Index Search

Request case numbers in Item Number 1.b.

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.)

Requestor's Signature

6.a.

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

1.a.

1.b. Genealogy Index Search Case Number

Other Names Used by the Immigrant

3.b.

3.c.

3.a. Family Name

(Last Name)

Given Name

(First Name)

Middle Name

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.

(USPS ZIP Code Lookup)