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.
Would
you prefer to receive your search results via e-mail or 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 $20.
(See Form G-1041 Instructions for more information.)
6.a.
Requestor’s Signature
6.b.
Date of Signature (mm/dd/yyyy)
|
Page 1,
Part II. Information
Needed to Search the Index
|
Part
II. Information Needed to Search the Index
A. Required Information
Immigrant's Full Name (If
appropriate, enter religious salutation before the first name -
Example: father, sister, etc.)
Last
Name
First
Name
Middle
Name
Other names used, maiden names,
aliases, or variant spellings (if any)
*Immigrant's Date of Birth (Check
only one): Actual/Estimated Day/Month/Full Year
Immigrant's
Country of Birth
(Include
Country, Province, Town/Village, if known)
|
[Page 1 ]
Part 2.
Immigrant’s
Information
[Deleted]
Full
Name of the Immigrant
[Sub-header]
1.a. Family
Name (Last Name)
1.b. Given
Name (First Name)
1.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.
2.a.
Family Name (Last Name)
2.b.
Given Name (First Name)
2.c.
Middle Name
[Page 2]
Other
Information About the Immigrant
[Sub-header]
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 [Fillable Field]
4.b.
Province [Fillable Field]
4.c.
Country [Fillable Field]
|
Page 1,
B.
Additional Information Useful to Identify a Given Immigrant From
Others With the Same Name
|
B. Additional Information Useful
to Identify a Given Immigrant From Others With the Same Name
Date of immigrant's exact arrival
in the United States:
(mm/dd/yyyy)
(If unsure or unknown of date
range, check additional choices below)
Before 1906
1906 to 1924
1924 to 1940
After 1940
Where
did the immigrant live in the United States?
(State,
city, or exact street address-Example: in Pennsylvania until 1938,
then lived in Madison,
Wisconsin)
Other
information about the immigrant that may prove useful in the index
search (name of spouse and/or children, date of immigrant's death,
military service, date of naturalization, date of female
immigrant's marriage, occupation):
*
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
instructions on Page
1 for examples
of acceptable documentary proof of death.
NOTE:
The fee for an
Index Search Request is $20.
|
[Page 2]
Part 3.
Other
Information
1. Date
of immigrant's exact arrival in the United States.
(mm/dd/yyyy)
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
2.d.
After 1940
Where
did the immigrant live in the United States?
3.a.
Street Number and Name
3.b.
Apt./Ste./Flr. [Fillable Field]
3.c.
City or Town
3.d.
State
3.e.
ZIP Code
3.f.
Postal Code
3.g.
Country
4.a.
Date From (mm/dd/yyyy)
4.b.
Date To (mm/dd/yyyy)
5.
List additional information about residences and dates below (if
any).
6.
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): [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 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.
[Deleted]
|