Form G-1041 09/17/19 Page 2 of 3
Part 3. Other Information
Date of immigrant's exact arrival in the United States
NOTE: If you are unsure of the date range, or it is unknown
select an additional choice in Item Numbers 2.a. - 2.d.
1924 to 1940
Before 1906
1906 to 1924
After 1940
Where did the immigrant live in the United States?
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):
(mm/dd/yyyy)
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.
1.
2.a.
2.b.
2.c.
2.d.
6.
City or Town3.c.
Street Number
and Name
3.a.
3.b. Apt.
Flr.Ste.
3.g. Country
3.f.
Postal Code
ZIP Code
3.e.
State
3.d.
Date From (mm/dd/yyyy)
4.a.
List additional information about residences and dates
below (if any).
Date To (mm/dd/yyyy)
4.b.
5.
Other Information About the Immigrant
Place of Birth (Include Town or Village, Province, and
Country, if known)
3.a.
Date of Birth (mm/dd/yyyy)
Actual Estimated
Is this date actual or estimated?3.b.
Town or Village4.a.
Province4.b.
Country 4.c.
Part 2. Immigrant's Information (continued)