Form I-924A Supplement to Form I-924

OMB No. 1615-0061; Expires 03/31/2016

Form I-924A,
Supplement to Form I-924

Department of Homeland Security
U.S. Citizenship and Immigration Services

Part 1. Information About Principal of the Regional Center
Name: Last

First

Middle

In Care Of:
Street Address/P.O. Box:
City:
Date of Birth
(mm/dd/yyyy):

State:

Zip Code:

Fax Number
(include area code):

Telephone Number
(include area code):

Web site address:
USCIS-assigned number for the Designated Regional Center (attach the
Regional Center's most recently issued approval notice)

Part 2. Application Type (Select one)
a. Supplement for the Fiscal Year Ending September 30,

(YYYY)

b. Supplement for a Series of Fiscal Years Beginning on October 1,

(YYYY) and Ending on September 30,

(YYYY)

Part 3. Information About the Regional Center
(Use a continuation sheet, if needed, to provide information for additional management companies/agencies, regional center
principals, agents, individuals, or entities who are or will be involved in the management, oversight, and administration of the regional
center.)
A. Name of Regional Center:
Street Address/P.O. Box:
City:
Web site
Address:

State:
Fax Number
(include area code):

Zip Code:
Telephone
(include area code):

B. Name of Managing Company/Agency:
Street Address/P.O. Box:
City:
Web site
Address:

State:
Fax Number
(include area code):

Zip Code:
Telephone
(include area code):

C. Name of Other Agent:
Street Address/P.O. Box:
City:
Web site
Address:

State:
Fax Number
(include area code):

Zip Code:
Telephone
(include area code):
Form I-924A 03/18/15 Y Page 1

Part 3. Information About the Regional Center (Continued)
Answer the following questions for the time period identified in Part 2 of this form. Note: If extra space is needed to complete any
item, attach a continuation sheet, indicate the item number, and provide the response.
1. Identify the aggregate EB-5 capital investment and job creation has been the focus of EB-5 capital investments sponsored through
the regional center. (Note: Separately identify jobs maintained through investments in “troubled businesses.”)
Aggregate EB-5 Capital Investment

Aggregate Jobs Maintained

Aggregate Direct and Indirect Job Creation

2. Identify each industry that has been the focus of EB-5 capital investments sponsored through the Regional Center, and the resulting
aggregate EB-5 capital investment and job creation. (Note: Separately identify jobs maintained through investments in “troubled
businesses”.)
a. Industry Category Title:

Aggregate EB-5 Capital Investment:

NAICS Code for the Industry Category

Aggregate Direct and Indirect Job Creation:

b. Industry Category Title:

Aggregate EB-5 Capital Investment:

NAICS Code for the Industry Category

Aggregate Direct and Indirect Job Creation:

c. Industry Category Title:

Aggregate EB-5 Capital Investment:

Aggregate Jobs Maintained:

Aggregate Jobs Maintained:

NAICS Code for the Industry Category

Aggregate Direct and Indirect Job Creation:

Aggregate Jobs Maintained:

3. Provide the following information for each job creating commercial enterprise located within the geographic scope of your
regional center that has received EB-5 investor capital:
a. Name of Commercial Enterprise:

Industry Category Title:

Address (Street Number and Name):

City:

State:

Aggregate EB-5 Capital Investment:

Aggregate Direct and Indirect Job Creation:

Aggregate Jobs Maintained:

Zip Code:

Does this EB-5 commercial enterprise serve as a vehicle for investment into other business entities that
have or will create or maintain jobs for EB-5 purposes?

No

Yes

Form I-924A 03/18/15 Y Page 2

Part 3. Information About the Regional Center (Continued)
If yes, then identify the name and address of each job creating business, as well as the amount of EB-5 capital investment and job
creation/maintenance associated with each job creating business.
Industry Category Title:

(1) Business Name:

Address (Street Number and Name):

City:

State:

EB-5 Capital Investment:

Direct and Indirect Job Creation:

Jobs Maintained:

(2) Business Name

Zip Code:

Industry Category Title:

Address (Street Number and Name):

City:

State:

EB-5 Capital Investment:

Direct and Indirect Job Creation:

Jobs Maintained:

b. Name of Commercial Enterprise:

Zip Code:

Industry Category Title:

Address (Street Number and Name):

City:

Aggregate EB-5 Capital Investment:

Aggregate Direct and Indirect Job Creation:

State:

Zip Code:

Aggregate Jobs Maintained:

Does this EB-5 commercial enterprise serve as a vehicle for investment into other business entities that
have or will create or maintain jobs for EB-5 purposes?

No

Yes

If yes, then identify the name and address of each job creating business, as well as the amount of EB-5 capital investment and job
creation/maintenance associated with each job creating business.
Industry Category Title:

(1) Business Name:

Address (Street Number and Name):

City:

EB-5 Capital Investment

Direct and Indirect Job Creation

State:

Zip Code

Jobs Maintained

Form I-924A 03/18/15 Y Page 3

Part 3. Information About the Regional Center (Continued)
(2) Business Name:

Industry Category Title:

Address (Street Number and Name):

City:

EB-5 Capital Investment:

Direct and Indirect Job Creation:

c. Name of Commercial Enterprise:

State:

Zip Code:

Jobs Maintained:

Industry Category Title:

Address (Street Number and Name):

City:

Aggregate EB-5 Capital Investment:

Aggregate Direct and Indirect Job Creation:

State:

Zip Code:

Aggregate Jobs Maintained:

Does this EB-5 commercial enterprise serve as a vehicle for investment into other business entities
that have or will create or maintain jobs for EB-5 purposes?

No

Yes

If yes, then identify the name and address of each job creating business, as well as the amount of EB-5 capital investment and job
creation/maintenance associated with each job creating business.
Industry Category Title:

(1) Business Name:

Address (Street Number and Name):

City:

State:

EB-5 Capital Investment:

Direct and Indirect Job Creation:

Jobs Maintained:

(2) Business Name:

Zip Code:

Industry Category Title:

Address (Street Number and Name):

City:

State:

EB-5 Capital Investment:

Direct and Indirect Job Creation:

Jobs Maintained:

Zip Code:

Form I-924A 03/18/15 Y Page 4

Part 3. Information About the Regional Center (Continued)
d. Name of Commercial Enterprise:

Industry Category Title:

Address (Street Number and Name):

City:

State:

Aggregate EB-5 Capital Investment:

Aggregate Direct and Indirect Job Creation:

Aggregate Jobs Maintained:

Zip Code:

Does this EB-5 commercial enterprise serve as a vehicle for investment into other business entities
that have or will create or maintain jobs for EB-5 purposes?

No

Yes

If yes, then identify the name and address of each job creating business, as well as the amount of EB-5 capital investment and
job creation/maintenance associated with each job creating business.
Industry Category Title:

(1) Business Name:

Address (Street Number and Name):

City:

State:

EB-5 Capital Investment:

Direct and Indirect Job Creation:

Jobs Maintained:

(2) Business Name:

Zip Code:

Industry Category Title:

Address (Street Number and Name):

City:

EB-5 Capital Investment:

Direct and Indirect Job Creation:

e. Name of Commercial Enterprise:

State:

Zip Code:

Jobs Maintained:

Industry Category Title:

Address Street Number and Name:

City:

State:

Aggregate EB-5 Capital Investment:

Aggregate Direct and Indirect Job Creation:

Aggregate Jobs Maintained:

Does this EB-5 commercial enterprise serve as a vehicle for investment into other business entities
that have or will create or maintain jobs for EB-5 purposes?

Zip Code:

No

Yes

Form I-924A 03/18/15 Y Page 5

Part 3. Information About the Regional Center (Continued)
If yes, then identify the name and address of each job creating business, as well as the amount of EB-5 capital investment and
job creation/maintenance associated with each job creating business.
Industry Category Title:

(1) Business Name:

Address (Street Number and Name):

City:

EB-5 Capital Investment:

Direct and Indirect Job Creation:

State:

Zip Code:

Jobs Maintained:

Industry Category Title:

(2) Business Name:

Address (Street Number and Name):

City:

State:

EB-5 Capital Investment:

Direct and Indirect Job Creation:

Zip Code:

Jobs Maintained:

4. Provide the total number of approved, denied and revoked Form I-526 petitions filed by EB-5 investors making capital
investments sponsored by the regional center. (Note: If an adverse action was ultimately reversed and the petition was approved,
then note the case as approved.)
Form I-526 Petition Final Case Actions
Approved

Denied

Revoked

5. Provide the total number of approved, denied and revoked Form I-829 petitions filed by EB-5 investors making capital
investments sponsored by the regional center. (Note: If an adverse action was ultimately reversed and the petition was approved,
then note the case as approved.)
Form I-829 Petition Final Case Actions
Approved

Denied

Revoked

NOTE: USCIS may require case-specific data relating to individual EB-5 petitions and the job creation determination and further
information regarding the allocation methodologies utilized by a regional center in certain instances in order to verify the aggregate
data provided above.

Form I-924A 03/18/15 Y Page 6

Part 4. Applicant Signature Read the information on penalties in the instructions before completing this section. If
someone helped you prepare this petition, he or she must compete Part 5.
I certify, under penalty of perjury under the laws of the United States of America, that this supplemental form and the evidence
submitted with it are all true and correct. I authorize the release of any information from my records that U.S. Citizenship and
Immigration Services needs to determine eligibility for the benefit being sought. I also certify that I have authority to act on behalf of
the Regional Center.
Signature of Applicant

Printed Name of Applicant

Daytime Phone Number
(Area/Country Codes)

E-Mail Address

Date (mm/dd/yyyy)

Relationship to the Regional Center Entity (Managing Member, President, CEO, etc.)

Part 5. Signature of Person Preparing This Form, If Other Than Above (Sign Below)
I declare that I prepared this form using information provided by someone with authority to act on behalf of the Regional Center, and
the answers and information are those provided by the Regional Center.
Attorney or Representative: In the event of a Request for Evidence (RFE), may the USCIS contact
you by Fax or E-mail?

Signature of Preparer

Printed Name of Preparer

No

Yes

Date (mm/dd/yyyy)

Firm Name and Address

Daytime Phone Number
(Area/Country Codes)

Fax Number (Area/
Country Codes)

E-Mail Address

Form I-924A 03/18/15 Y Page 7