Please fill out this form as thoroughly
as possible and return to:
TIPCOA, P.O. Box 2464, West Lafayette,
IN 47996
Please submit a separate form for each person to be researched. Please print:
Your Name: _____________________________ Address: ______________________________
City: __________________________________ State: ________ ZIP: __________________
Phone: (______)_________________________ E-Mail: _______________________________
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Ancestor's Name: ________________________________________________________________
Date of Birth: ________________________ Place of Birth: _________________________
Date of Death: ________________________ Place of Death: _________________________
Father: _______________________________ Mother: _________________________________
Spouse: _________________________________________________________________________
Marriage Info: __________________________________________________________________
Names of Children: ______________________________________________________________
_________________________________________________________________________________
What you would like us to research?: ____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Places and records you have already researched: _________________________________
_________________________________________________________________________________
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For office use only.:
Received __________________
Assigned _________________ Completed __________________
Mailed ___________________
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