Form G-1041A Genealogy Records Request

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

USCIS
Form G-1041A

OMB No. 1615-0096
Expires 05/31/2019

► 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 $65. (See Form
G-1041A 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
2.a. In Care Of Name (if any)

Part 2. Information Needed to Release a
Historical Record

2.b. Street Number
and Name

1.a. Is the file information provided below the result of a
previous Genealogy Index Search Request?
Yes
No

2.c.

Apt.

Ste.

Flr.

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

If you answered "Yes," provide the Genealogy Index Search
Request case numbers in Item Number 1.b.
1.b. Genealogy Index Search Case Number

2.f.

ZIP Code

2.g. Province

Full Name of the Immigrant

2.h. Postal Code

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

2.i.

Country

2.c. Middle Name

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)

Other Names Used by the Immigrant
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.
3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)
3.c. Middle Name

Form G-1041A 12/23/16 N

Page 1 of 3

Part 2. Information Needed to Release a
Historical Record (continued)
Other Information for the Immigrant

Fee (Select all appropriate boxes)
$65 (Microfilm)

$65 (Hard Copy)

Non-standard C-Files (B, D, OM, OS, A, AA, OL)

4.a. Date of Birth (mm/dd/yyyy)
4.b. Is this date actual or estimated?

1.f.

2.a. Number as Shown on Certificate
►
Actual

Estimated

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

2.b. Date of Issuance (mm/dd/yyyy)

Alien Registration Record (AR-2) (1940 - 1944)

5.b. Province

3.a. Alien Registration Number (A-Number)
► A or AR

5.c. Country

3.b. Fee

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.

$65 (Copy Format - Microfilm)

A-File numbered below 8 million
4.a. A-File Number
4.b. Fee

►A

$65 (Copy Format - Hard Copy)

Visa File (1924 - 1944)

Part 3. Identification of Requested Record

5.a. Visa Number ►

NOTE (C-file numbered C650000 and below): The fee for a
copy of a microfilm record is $65 per request.

5.b. Date of Entry (mm/dd/yyyy)

NOTE (C-file numbered C650000 and below): The fee for a
copy of a textual hard copy file is $65 per request.
NOTE: If you are a researcher providing a C-file number
below C-650000 obtained from any source other than the
USCIS Genealogy Program, you may not know the format of
the file (microfilm or hard copy).

Naturalization Certificate File (1906 - 1956)
1.a. Certificate Number

►C

1.b. Date of Naturalization (mm/dd/yyyy)
1.c. Court

5.c. Port-of-Entry
5.d. Ship (seaport arrivals only)

5.e. Fee

$65 (Copy Format - Hard Copy)

Registry File (1929 - 1944)
6.a. Registry File Number
6.b. Fee

►R

$65 (Copy Format - Hard Copy)
Total Fees Due/Attached

$

1.d. City
1.e. County

Form G-1041A 12/23/16 N

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.

4.b. Part Number

4.c. Item Number

5.b. Part Number

5.c. Item Number

6.b. Part Number

6.c. Item Number

4.d.

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
5.a. Page Number

2.d.
5.d.

3.a. Page Number

3.b. Part Number

3.c. Item Number
6.a. Page Number

3.d.
6.d.

Form G-1041A 12/23/16 N

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