G-1041 Genealogy Index Search Request,

Genealogy Index Search Request
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form G-1041
OMB No. 1615-0096
Expires 12/31/2015

DRAFT
Not for
Production
03/16/16

► START HERE - Type or print in black ink.

Part 1. Information About You (Requestor)

Requestor's Certification

Requestor's Full Name

By my signature, I consent to pay all costs incurred for search,
duplication, and review of documents up to $20. (See Form
G-1041 Instructions for more information.)

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

6.a. Requestor's Signature

1.c. Middle Name

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

Requestor's Mailing Address

Part 2. Immigrant's Information

2.a. In Care Of Name (if any)

Full Name of the Immigrant

2.b. Street Number
and Name
2.c.

Apt.

Ste.

1.c. Middle Name

2.d. City or Town
2.e. State

Flr.

2.f.

2.g. Province

ZIP Code

2.h. Postal Code
2.i.

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

Country

Requestor's Contact Information
3.

Requestor's Daytime Telephone Number

4.

Requestor's Mobile Telephone Number (if any)

5.

Requestor's Email Address (if any)

Form G-1041 12/17/12 Y

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.
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)
2.c. Middle Name

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Part 2. Requestor's Information (continued)

5.

List additional information about residences and dates
below (if any).

Other Information About the Immigrant

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Production
03/16/16

3.a. Date of Birth (mm/dd/yyyy)

3.b. Is this date actual or estimated?

Actual

Estimated

Place of Birth (Include Town or Village, Province, and
Country, if known)
4.a. Town or Village
4.b. Province
4.c. Country

Part 3. Other Information
1.

Date of immigrant's exact arrival in the United States
(mm/dd/yyyy)

6.

NOTE: If you are unsure of the date range, or it is unknown
select an additional choice in Item Numbers 2.a. - 2.d.
2.a.

Before 1906

2.b. 1906 to 1924
2.c.

1924 to 1940

Other information about the immigrant that may prove
useful in the index search (For example, name of spouse
and/or children, date of immigrant's death, military
service, date of naturalization, date of female immigrant's
marriage, occupation):

2.d. After 1940
Where did the immigrant live in the United States?
3.a. Street Number
and Name
3.b.

Apt.

Ste.

Flr.

3.c. City or Town
3.d. State
3.f.

3.e. ZIP Code

Postal Code

3.g. Country

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 this request. Do not attach
original records because we will not return them. See the What
Information Is Required to Begin an Index Search section of
the Instructions for examples of acceptable documentary proof
of death.

4.a. Date From (mm/dd/yyyy)
4.b. Date To (mm/dd/yyyy)

Form G-1041 12/17/12 Y

Page 2 of 3

4.a. Page Number

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

4.c. Item Number

4.d.

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Production
03/16/16

2.a. Page Number 2.b. Part Number

2.c. Item Number

5.a. Page Number

2.d.

4.b. Part Number

5.b. Part Number

5.c. Item Number

6.b. Part Number

6.c. Item Number

5.d.

3.a. Page Number 3.b. Part Number

3.c. Item Number

6.a. Page Number

3.d.
6.d.

Form G-1041 12/17/12 Y

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