Form I-924A Supplement to Form I-924

Form I-924A, Annual Certification of Regional Center

If you need extra space to complete any section of this request or if you would like to provide additional information about your circumstances, use the space provided in Part 11. Additional Information. Complete and submit as many copies of Part 11., as necessary, with your request.

START HERE - Type or print in black ink.

Part 1. Information About the Regional Center

1. Name of Regional Center Entity

2. Name of Regional Center (if different from regional center entity)

3. Regional Center Identification Number

4. Regional Center Receipt Number

Regional Center Mailing Address

5.a. In Care Of Name (if any)

5.b. Street Number and Name or PO Box

5.c. Apt. Ste. Flr.

5.d. City or Town

5.e. State

5.f. ZIP Code

Regional Center Contact Information

6. Daytime Telephone Number

7. Fax Number

8. Email Address (if any)

9. Website Address (if any)

NOTE for Regional Center Mailing Address: If the regional center mailing address is different from the physical address, please provide the physical address of the regional center in the space provided in Part 11. Additional Information.

Part 2. Information About the Managing Company or Agency (if different from regional center entity)

1. Name of Managing Company or Agency

Managing Company or Agency Mailing Address

2.a. In Care Of Name (if any)

2.b. Street Number and Name or PO Box

2.c. Apt. Ste. Flr.

2.d. City or Town

2.e. State

2.f. ZIP Code

Contact Information for Managing Company or Agency

3. Daytime Telephone Number

4. Fax Number

5. Email Address (if any)

6. Website Address (if any)

NOTE for Multiple Managing Companies or Agencies: If more than one managing company or agency is associated with the regional center, provide the above information for all other managing companies or agencies in the space provided in Part 11. Additional Information.

Part 3. Reporting Period for Regional Center Activity

Select only one box.

1. Reporting for the Federal fiscal year ending September 30, (yyyy).

2. Reporting for a series of Federal fiscal years beginning October 1, (yyyy) and ending September 30, (yyyy).

Part 4.  Information About the Organizational Structure, Ownership, and Control of Regional Center Entity

Information About the Principal Owners of the Regional Center Entity

List and provide the required information for all persons or legal entities or organizations that own or have a percentage of ownership in the regional center entity.

1.a. Family Name (Last Name)

1.b. Given Name (First Name)

1.c. Middle Name

2. Date of Birth (mm/dd/yyyy)

3. Country of Birth

4. U.S. Social Security Number (if any)

5. Percentage of Ownership of the Regional Center Entity %

6. Position Held Within the Regional Center Entity (if any)

7. Entity Name (for an owner of the Regional Center Entity that is an entity or organization)

8. Federal Employer Identification Number (for an owner of the Regional Center Entity that is an entity or organization)

9.a9. Persons Having Ownership, Control or Beneficial Interest in the Entity Listed in Part 4., Item Number 7.

9.b10. Date of Birth (mm/dd/yyyy)

9.c11. Country of Birth

9.d12. Percentage of Ownership in the Entity Listed in Part 4., Item Number 7. %

9.e13. Position Held (if any) in the Entity Listed in Part 4., Item Number 7.

Other Names Used By the Principal Owner of the Regional Center Entity (if applicable)

1014.a. Family Name (Last Name)

1014.b. Given Name (First Name)

1014.c. Middle Name

1115. Trade Name (DBA if any) (for the entity listed in Part 4., Item Number 7.)

Mailing Address for the Principal Owner of the Regional Center Entity

1216.a. In Care Of Name (if any)

1216.b. Street Number and Name or PO Box

1216.c. Apt. Ste. Flr.

1216.d. City or Town

1216.e. State

1210.f. ZIP Code

1216.g. Province

1216.h. Postal Code

1216.i. Country

Contact Information for the Principal Owner of the Regional Center Entity

1317. Daytime Telephone Number

1418. Fax Number

1519. Email Address (if any)

1620. Website Address (if any)

Information About the Principal Non-Owner of the Regional Center Entity

List and provide the required information for all principals associated with the regional center, other than those already identified in Part 4., Item Numbers 1.a. - 1120.

1721.a. Family Name (Last Name)

1721.b. Given Name (First Name)

1721.c. Middle Name

2218. Date of Birth (mm/dd/yyyy)

1923. Country of Birth

2024. U.S. Social Security Number (if any)

2125. Position Held Within the Regional Center Entity

2226. Entity Name (for a principal of the Regional Center Entity that is an entity or organization)

2327. Federal Employer Identification Number (for a principal of the Regional Center Entity that is an entity or organization)

24.a28. Persons Having Ownership, Control, or Beneficial Interest in the Entity Listed in Part 4., Item Number 2226.

24.b29. Date of Birth (mm/dd/yyyy)

24.c30. Country of Birth

24.d31. Percentage of Ownership in the Entity Listed in Part 4., Item Number 2226. %

24.e32. Position Held (if any) in the Entity Listed in Part 4., Item Number 2226.

Other Names Used By the Principal Non-Owner of the Regional Center Entity (if applicable)

2533.a. Family Name (Last Name)

2533.b. Given Name (First Name)

2533.c. Middle Name

2634. Trade Name (DBA if any) (for the entity listed in Part 4., Item Number 2226.

Mailing Address for the Principal Non-Owner of the Regional Center Entity

2735.a. In Care Of Name (if any)

2735.b. Street Number and Name or PO Box

2735.c. Apt. Ste. Flr.

2735.d. City or Town

2735.e. State

2735.f. ZIP Code

2735.g. Province

2735.h. Postal Code

2735.i. Country

Contact Information for the Principal Non-Owner of the Regional Center Entity

2836. Daytime Telephone Number

2937. Fax Number

3038. Email Address (if any)

3139. Website Address (if any)

Part 5. Information About the Regional Center's Operations

Aggregate Capital Investment and Job Creation

Provide the aggregate capital investment and job creation that has been the focus of the EB-5 capital investments sponsored through the regional center. NOTE: Please indicate the number of jobs maintained through investments in “troubled businesses” separate from aggregate job creation as indicated below.

1. Aggregate EB-5 Capital Investment From All Sponsored Projects

2. Aggregate Non-EB-5 Capital Investment From All Sponsored Projects

3. Aggregate Number of Direct, Indirect, and/or Induced Jobs Created For All Sponsored Projects

4. Aggregate Number of Jobs Maintained Through Investment in Troubled Businesses

Industries and Resulting Aggregate Capital Investment and Job Creation

Identify each industry and the resulting aggregate capital investment and job creation from the EB-5 capital investments sponsored through the regional center.

5. Name of Industry

6. North American Industry Classification System (NAICS) Code for the Industry Category

7. Aggregate EB-5 Capital Investment

8. Aggregate Non-EB-5 Capital Investment

9. Aggregate Number of Direct, Indirect, and/or Induced Jobs Created

10. Aggregate Number of Jobs Maintained Through Investment in Troubled Businesses

11. Name of Industry

12. NAICS Code for the Industry Category

13. Aggregate EB-5 Capital Investment

14. Aggregate Non-EB-5 Capital Investment

15. Aggregate Number of Direct, Indirect, and/or Induced Jobs Created

16. Aggregate Number of Jobs Maintained Through Investment in Troubled Businesses

Part 6. Information About the New Commercial Enterprise

Provide the following information for each new commercial enterprise associated with the regional center that has received EB-5 investor capital. If the regional center oversees more than one new commercial enterprise, provide the information below for each additional new commercial enterprise in Part 11. Additional Information.

NOTE: Please indicate the number of jobs maintained through investments in “troubled businesses” separate from aggregate job creation as indicated below.

1. Name of the New Commercial Enterprise

2. New Commercial Enterprise Federal Employer Identification Number

New Commercial Enterprise Mailing Address

3.a. In Care Of Name (if any)

3.b. Street Number and Name or PO Box

3.c. Apt. Ste. Flr.

3.d. City or Town

3.e. State

3.f. ZIP Code

NOTE for New Commercial Enterprise Mailing Address: If the new commercial enterprise mailing address is different from the physical address, please provide the physical address of the new commercial enterprise in the space provided in Part 11. Additional Information.

Other Information

4. Name of Industry Receiving Investment Capital From the New Commercial Enterprise

5. NAICS Code for the Industry Category

If more than one industry is receiving investment capital from the new commercial enterprise, provide the name and NAICS code for each additional industry category in the space provided in Part 11. Additional Information.

6. Aggregate EB-5 Capital Investment

7. Aggregate Non-EB-5 Capital Investment

8. Aggregate Number of Direct, Indirect, and/or Induced Jobs Created

9. Aggregate Number of Jobs Maintained Through Investment in Troubled Businesses

10. Does the new commercial enterprise serve as a vehicle for investment into other job creating entities that have or will create or maintain jobs for EB-5 purposes? Yes No

If you answered “Yes” to Item Number 10., identify the name and address of each job creating entity, its industry, as well as the aggregate capital investment and job creation associated with each job creating entity.

NOTE: Please indicate the number of jobs maintained through investments in “troubled businesses” separate from aggregate job creation as indicated below.

Information About the Job Creating Entity

11. Entity Name

12. Job Creating Entity Federal Employer Identification Number

13. Name of Industry If more than one industry is associated with the job creating entity, provide the name for each additional industry category in the space provided in Part 11. Additional Information.

Mailing Address

14.a. In Care Of Name

14.b. Street Number and Name or PO Box

14.c. Apt. Ste. Flr.

14.d. City or Town

14.e. State

14.f. ZIP Code

15. Aggregate EB-5 Capital Investment

16. Aggregate Non-EB-5 Capital Investment

17. Aggregate Number of Jobs Created

18. Aggregate Number of Jobs Maintained Through Investment in Troubled Businesses

NOTE: If the address in Item Numbers 14.a. - 14.f. of this section refers to the mailing address of the job creating entity, please provide the physical address of the new commercial enterprise in the space provided in Part 11. Additional Information.

Part 7. Petitions Filed by EB-5 Investors

Immigrant Petition by Alien Entrepreneur (Form I-526)

Provide the total number of approved, denied, and revoked Form I-526, Immigrant Petition by Alien Entrepreneur, petitions filed by EB-5 investors making capital investments in each new commercial enterprise associated with the regional center.

NOTE: If an adverse action was ultimately reversed and the petition was approved, then list the case as approved.

Form I-526 Petition Final Case Actions

1. Name of the New Commercial Enterprise

2. Select only one result.

Approved

Denied

Revoked

Petition By Entrepreneur to Remove Conditions (Form I-829)

Provide the total number of approved and denied Form I-829, Petition by Entrepreneur to Remove Conditions, petitions filed by EB-5 investors making capital investments in each new commercial enterprise associated with the regional center.

Form I-829 Petition Final Case Actions

3. Name of New Commercial Enterprise

4. Select only one result.

Approved

Denied

Part 8.  Statement, Contact Information, Declaration, Certification, and Signature of the Applicant or Authorized Signatory Individual

NOTE: Read the Penalties section of the Form I-924A Instructions before completing this part.

Applicant's or Authorized Signatory's Individual’s Statement

Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2.

1.a. I can read and understand English, and I have read and understand each and every question and instruction on this application form and my answer to each question.

1.b. The interpreter named in Part 9. has read to me every question and instruction on this application form and my answer to every question in _____, a language in which I am fluent.  I understood all of this information as interpreted.

2. At my request, the preparer named in Part 10., _________, prepared this applicationform for me based only upon information I provided or authorized.

Authorized SignatoryIndividual's Contact Information

3.a. Authorized SignatoryIndividual's Family Name (Last Name)

3.b. Authorized SignatoryIndividual's Given Name (First Name)

4. Authorized SignatoryIndividual's Title

5. Authorized SignatoryIndividual's Daytime Telephone Number

6. Authorized SignatoryIndividual's Mobile Telephone Number (if any)

7. Authorized SignatoryIndividual's Email Address (if any)

Applicant's or Authorized SignatoryIndividual's Declaration and Certification

Copies of any documents submitted are exact photocopies of unaltered, original documents, and I understand that, as the applicantauthorized individual, I may be required to submit original documents to USCIS at a later date.

I authorize the release of any information from my records, or from the petitioning organization's records, to USCIS or other entities and persons where necessary to determine eligibility for the immigration benefit sought or where authorized by law. I recognize the authority of USCIS to conduct audits of this applicationform using publicly available open source information. I also recognize that any supporting evidence submitted in support of this applicationform may be verified by USCIS through any means determined appropriate by USCIS, including but not limited to, on-site compliance reviews.

If I am filing this petition form on behalf of an organizationthe regional center entity, and I certify that I am authorized to do so by the organizationregional center entity.

I certify, under penalty of perjury, that I have reviewed this applicationform, I understand all of the information contained in, and submitted with, my this formapplication, and all of this information is complete, true, and correct.

Applicant's or Authorized SignatoryIndividual's Signature

8.a. ApplicantAuthorized Individual Signature

8.b. Date of Signature (mm/dd/yyyy)

NOTE TO ALL APPLICANTS REGIONAL CENTERS AND AUTHORIZED SIGNATORIESINDIVIDUALS: If you do not completely fill out this applicationform or fail to submit required documents listed in the Instructions, USCIS may delay a decision on or denyreject your applicationform. USCIS will issue a notice of intent to terminate the participation of the regional center in the Immigrant Investor Program if a regional center fails to submit the required information or upon a determination that the regional center no longer serves the purpose of promoting economic growth.

Part 9.  Interpreter's Contact Information, Certification, and Signature

Provide the following information about the interpreter.

Interpreter's Full Name

1.a. Interpreter's Family Name (Last Name)

1.b. Interpreter's Given Name (First Name)

2. Interpreter's Business or Organization Name (if any)

Interpreter's Mailing Address

3.a. Street Number and Name

3.b. Apt. Ste. Flr.

3.c. City or Town

3.d. State

3.e. ZIP Code

3.f. Province

3.g. Postal Code

3.h. Country

Interpreter's Contact Information

4. Interpreter's Daytime Telephone Number

5. Interpreter's Mobile Telephone Number (if any)

6. Interpreter's Email Address (if any)

Interpreter's Certification

I certify, under penalty of perjury, that:

I am fluent in English and ___________, which is the same language provided in Part 8., Item Number 1.b., and I have read to this applicant or the authorized signatoryindividual in the identified language every question and instruction on this application form and his or her answer to every question. The applicant or authorized signatoryindividual informed me that he or she understands every instruction, question, and answer on the formapplication, including the Applicant's or Authorized Signatory's Individual’s Declaration and Certification, and has verified the accuracy of every answer.

Interpreter's Signature

7.a. Interpreter's Signature

7.b. Date of Signature (mm/dd/yyyy)

Part 10.  Contact Information, Declaration, and Signature of the Person Preparing this ApplicationForm, if Other Than the ApplicantAuthorized Individual

Provide the following information about the preparer.

Preparer's Full Name

1.a. Preparer's Family Name (Last Name)

1.b. Preparer's Given Name (First Name)

2. Preparer's Business or Organization Name (if any)

Preparer's Mailing Address

3.a. Street Number and Name

3.b. Apt. Ste. Flr.

3.c. City or Town

3.d. State

3.e. ZIP Code

3.f. Province

3.g. Postal Code

3.h. Country

Preparer's Contact Information

4. Preparer's Daytime Telephone Number

5. Preparer's Mobile Telephone Number (if any)

6. Preparer's Email Address (if any)

Preparer's Statement

7.a. I am not an attorney or accredited representative but have prepared this application form on behalf of the applicantauthorized individual and with the applicantauthorized individual's consent.

7.b. I am an attorney or accredited representative and my representation of the applicantauthorized individual in this case extends/does not extend beyond the preparation of this applicationform.

NOTE: If you are an attorney or accredited representative whose representation extends beyond preparation of this applicationform, you may be obliged to submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, with this applicationform.

Preparer's Certification

By my signature, I certify, under penalty of perjury, that I prepared this application form at the request of the applicant or authorized signatoryindividual. The authorized individual applicant has reviewed this completed applicationform, including the Applicant's or Authorized Signatory's Individual’s Declaration and Certification, and informed me that all of this information in the form and in the supporting documents is complete, true, and correct.

Preparer's Signature

8.a. Preparer's Signature

8.b. Date of Signature (mm/dd/yyyy)

Part 11. Additional Information

If you need extra space to provide any additional information within this applicationform, use the space below. If you need more space than what is provided, you may make copies of this page to complete and file with this applicationform or attach a separate sheet of paper. Type or print the regional center entity's name at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet.

1. Name of Regional Center Entity

2. Regional Center Identification Number

3.a. Page Number

3.b. Part Number

3.c. Item Number

3.d. __________

4.a. Page Number

4.b. Part Number

4.c. Item Number

4.d. __________

5.a. Page Number

5.b. Part Number

5.c. Item Number

5.d. __________

6.a. Page Number

6.b. Part Number

6.c. Item Number

6.d. __________