Form G-1041A Geneology Records Request

Historical Records Services Request

G-1041A Form

Historical Records Services Request

OMB: 1615-0096

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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.

First Name

Last Name

Middle Name

Suffix (Jr., Sr.)

Apartment No.

Address (Number and Street Name, P.O. Box Number or Route Number)

City

State/Province

E-Mail Address: (If available)

Daytime Telephone Number: (Include Area/Country Code, ext.)

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. 09/10/08)Y

Part III. Identification of Requested Record(s)
File Number/File Information

Type of File(s)
Requested
Naturalization
Certificate File
1906-1956

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
Check one or
both fees

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. 09/10/08)Y Page 2


File Typeapplication/pdf
File TitleGenealogy Immigration Records Request
AuthorLinda Norford
File Modified2008-09-11
File Created2006-11-16

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