G-1041A, efile Genealogy Records Request, efile

DHS Privacy Notice
G-1041/A
AUTHORITIES: The information requested on this historical records request, and the associated
evidence, is collected under 8 CFR §§103.38 through 103.41.
PURPOSE: The primary purpose for providing the requested information on this request form is
to assist USCIS with identifying and obtaining copies of the requested USCIS historical records.
DISCLOSURE: The information you provide is voluntary. However, failure to provide the
requested information, and any requested evidence, prevents USCIS from processing your request.
ROUTINE USES: DHS may share the information you provide on this form with other federal,
state, local, and foreign government agencies and authorized organizations. DHS follows approved
routine uses, as described in the associated published system of records notice [DHSUSCIS/ICE/CBP-001 Alien File, Index, and National File Tracking System of Records] and as
described in the published privacy impact assessment [DHS/USCIS/PIA-017(a) Microfilm
Digitization Application System], which you can find at www.dhs.gov/privacy. DHS may also
share the information, as appropriate, for law enforcement purposes or in the interest of national
security.

USCIS Form G-1041 and G-1041A

Paperwork Reduction Act
USCIS may not conduct or sponsor an information collection, and you are not required to respond to a
collection of information, unless it displays a currently valid Office of Management and Budget (OMB)
control number. The public reporting burden for this collection of information is estimated at 0.3 hours
per response, including the time for reviewing instructions, gathering the required documentation and
information, completing the request, preparing statements, attaching necessary documentation, and
submitting the request. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to: U.S. Citizenship and
Immigration Services, Office of Policy and Strategy, Regulatory Coordination Division, 5900 Capital
Gateway Drive, Mail Stop #2140, Camp Springs, MD 20588-0009; OMB No. 1615-0096. Do not mail
your completed Form G-1041 to this address.