G-1041a

TABLE OF CHANGES – FORM

Form G-1041A,

Genealogy Records Request

OMB Number: 1615-0096

03/15/2016

Reason for Revision: Incorporating standard language updates and formatting changes.

Current Page Number and Section	Current Text	Proposed Text
Page 1	START HERE - Type or print in black ink and read all instructions before completing this form.	[Page 1] START HERE - Type or print in black ink.
Page 1, Part I. Information About You	Part I. Information About You Full Name Salutation: Mr. Mrs. Ms. Last Name First Name Middle Name Suffix (Jr., Sr.) Address (Number and Street Name, P.O. Box Number or Route Number) Apartment No. City State/Province Country (if other than U.S.) Zip/Postal Code 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? E-mail/Postal mail	[Page 1] Part 1. Information About You (Requestor) Requestor’s Full Name [Sub-header] 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name Requestor’s Mailing Address [Sub-header] 2.a. In Care of Name (if any) 2.b. Street Number and Name 2.c. Apt./Ste./Flr. [Fillable Field] 2.d. City or Town 2.e. State 2.f. ZIP Code 2.g. Province 2.h. Postal Code 2.i. Country Requestor’s Contact Information [Sub-header] 3. Requestor’s Daytime Telephone Number 4. Requestor’s Mobile Telephone Number (if any) 5. Requestor’s Email Address (if any) [Deleted] Requestor’s Certification [Sub-header] By my signature, I consent to pay all costs incurred for search, duplication, and review of documents up to $35. (See Form G-1041A Instructions for more information.) 6.a. Requestor’s Signature 6.b. Date of Signature (mm/dd/yyyy)
Page 1, Part II. Information Needed to Release a Historical Record	Part II. Information Needed to Release a Historical Record Is the file information provided below the result of a previous Genealogy Index Search Request? Yes/No If "Yes," provide the Genealogy Index Search Request case number(s): Immigrant's Full Name (If appropriate, enter religious salutation before the first name - Example: father, sister, etc.) Other names used, maiden names, aliases, or variant spellings (if any) Immigrant's Date of Birth* (Day/Month/Full Year) Check only one: Actual/Estimated Immigrant's Country of Birth (include Country, Province, Town/Village, if known) *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.	[Page 1 ] 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 [Fillable Field] Full Name of the Immigrant [Sub-header 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name Other Names Used by the Immigrant [Sub-header] 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. 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name Other Information for the Immigrant [Sub-header] 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 [Fillable Field] 5.b. Province [Fillable Field] 5.c. Country [Fillable Field] 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. [Deleted]
Page, 2 Part III. Identification of Requested Record(s)	*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. Type of File(s) Requested File Number/File Information Fee Check one or both fees Naturalization Certificate File 1906-1956 Certificate Number (up to 7 digits): C _ _ _ _ _ _ _ Date of Naturalization: Day Month Full Year Court City/County State $20M*/ $35HC** Non-standard C-Files (B, D, OM, OS, A, AA, OL) Number as Shown on Certificate: Date of Issuance: Day Month Full Year Alien Registration Record (AR-2), 1940-1944 Alien Registration Number (must be 7 digits): A- or AR- $20 M* A-File numbered below 8 million A-File Number (must be 7 digits): A- $35 HC** Visa File 1924-1944 Visa Number (up to 7 digits): Visa # Date of Entry: Day Month Full Year Port of Entry: Ship (seaport arrivals only): $35 HC** Registry File 1929-1944 Registry File Number (up to 6 digits): R $35 HC** Total Fees Due/Attached: $ Fillable Field NOTE: 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.	[Page 2] Part 3. Identification of Requested Record NOTE (C-file numbered C650000 and below): The fee for a copy of a microfilm record is $20 per request. NOTE (C-file numbered C650000 and above): The fee for a copy of a textual hard copy file is $35 per request. NOTE: 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. [Deleted] [Deleted] [Deleted] Naturalization Certificate File (1906-1956) 1.a. Certificate Number 1.b. Date of Naturalization (mm/dd/yyyy) 1.c. Court 1.d. City 1.e. County [Deleted] 1.f. Fee (Select all appropriate boxes) $20 (Microfilm)/$35 (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 $20 (Copy Format - Microfilm) A-File numbered below 8 million 4.a. A-File Number A- 4.b. Fee $35 (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 5.d. Ship (seaport arrivals only) 5.e. Fee $35 (Copy Format - Hard Copy) Registry File (1929-1944) 6.a. Registry File Number R 6.b. Fee $35 (Copy Format - Hard Copy) Total Fees Due/Attached: $ Fillable Field
[New]		[Page 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 2.d. [Fillable field] 3.a. Page Number 3.b. Part Number 3.c. Item Number 3.d. [Fillable field] 4.a. Page Number 4.b. Part Number 4.c. Item Number 4.d. [Fillable field] 5.a. Page Number 5.b. Part Number 5.c. Item Number 5.d. [Fillable field] 6.a. Page Number 6.b. Part Number 6.c. Item Number 6.d. [Fillable field]

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