Form I-924A
Supplement to Form I-924, Application For Regional Center Under the Immigrant Investor Program
Content from 10/20/2014 version
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Form I-924A, Annual Certification of Regional Center
Content from 3/14/2016 version
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[page 1]
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
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. Web site Address (if any)
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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. Web site 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.
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[page 1]
Part 2. Information About 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
2.b.
Street Number and Name or PO Box
[page 4]
Part 6. Information About New Commercial Enterprise
Provide the following information for each new commercial enterprise located within the geographic scope of 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 new commercial enterprise in the space provided in Part 11. Additional Information.
1. Name of New Commercial Enterprise
Mailing Address
2.a. In Care Of Name
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
Other Information
3.a.
Name
of Industry 3.b. NAICS Code for Industry Category
3.c. Aggregate EB-5 Capital Investment 3.d. Aggregate Non-EB-5 Capital Investment 3.e. Aggregate Number of Direct, Indirect, and/or Induced Jobs Created 3.f. Aggregate Number of Jobs Maintained through Investments in Troubled Businesses 3.g. Does the new commercial enterprise serve as a vehicle for investment into other business entities that have or will create or maintain jobs for EB-5 purposes? Yes/No
[page 5]
If you answered "Yes" to Item Number 3.g., identify the name and address of each job creating entity as well as the amount of EB-5 capital investment and job creation/maintenance associated with each job creating entity.
Information About the Job Creating Entity
4.a. Entity Name
4.b. Name of Industry
Other Information About the Job Creating Entity
5.a. Street Number and Name or PO Box 5.b. Apt. Ste. Flr. 5.c. City or Town 5.d. State 5.e. ZIP Code
6.a. Aggregate EB-5 Capital Investment 6.b. Aggregate Non-EB-5 Capital Investment 6.c. Aggregate Number of Direct, Indirect, and/or Induced Jobs Created 6.d. Aggregate Number of Jobs Maintained through Investment in Troubled Businesses
If you need extra space to complete this section, use the space provided in Part 11. Additional Information.
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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 Direct, Indirect, and/or Induced 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.
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[page 5]
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 sponsored by 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.a.
Approved
1.b. Denied
1.c.
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 sponsored by the regional center.
Form I-829 Petition Final Case Actions
2.a. Approved 2.b. Denied
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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
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[page 5]
Part 8. Statement, Contact Information, Certification, and Signature of the Authorized Individual
NOTE: 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 have read and understand every question and instruction on this supplement, as well as my answer to every question.
1.b. The interpreter named in Part 9. has also read to me every question and instruction on this supplement, as well as my answer to every question, in [fillable box], a language in which I am fluent. I understand every question and instruction on this supplement as translated to me by my interpreter, and have provided complete, true, and correct responses in the language indicated above.
2. I have requested the services of and consented to [fillable box], who is/ is not an attorney or accredited representative, preparing this supplement for me.
[page 6]
Authorized Individual's Contact Information
3.a. Authorized Individual's Family Name (Last Name)
3.b.
Authorized Individual's Given Name (First Name)
4. Authorized Individual's Title
5. Authorized Individual's Daytime Telephone Number
6. Authorized Individual's Mobile Telephone Number (if any)
7. Authorized Individual's Email Address (if any)
8. Authorized Individual's Web site Address (if any)
Authorized Individual's Certification
Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may require the regional center to submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from the regional center's records that USCIS may need to determine the regional center's continued eligibility.
I also authorize release of information contained in this supplement, in supporting documents, and in USCIS records, to other entities and persons where necessary for the administration of U.S. immigration laws and, as appropriate, for law enforcement purposes or in the interest of national security.
I certify, under penalty of perjury, that the information in this supplement and any documents submitted with this supplement are complete, true and correct. I am filing this supplement on behalf of the regional center entity, and I certify that I am empowered to do so by the regional center entity.
Authorized Individual's Signature
9.a. Authorized Individual's Signature
9.b.
Date of Signature
(mm/dd/yyyy)
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Part 8. Statement, Contact Information, Declaration, Certification, and Signature of the Authorized Individual
NOTE: Read the Penalties section of the Form I-924A Instructions before completing this part.
Applicant's or Authorized 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 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 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 form for me based only upon information I provided or authorized.
Authorized Individual’s Contact Information
3.a. Authorized Individual’s Family Name (Last Name) 3.b. Authorized Individual’s Given Name (First Name)
4. Authorized Individual’s Title
5. Authorized Individual’s Daytime Telephone Number
6. Authorized Individual’s Mobile Telephone Number (if any)
7. Authorized Individual’s Email Address (if any)
Authorized Individual’s Declaration and Certification
Copies of any documents submitted are exact photocopies of unaltered, original documents, and I understand that, as the authorized individual’s, 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 form using publicly available open source information. I also recognize that any supporting evidence submitted in support of this form may be verified by USCIS through any means determined appropriate by USCIS, including but not limited to, on-site compliance reviews.
I am filing this form on behalf of the regional center entity, and I certify that I am authorized to do so by the regional center entity.
I certify, under penalty of perjury, that I have reviewed this form, I understand all of the information contained in, and submitted with, this form, and all of this information is complete, true, and correct.
Authorized Individual’s Signature
8.a. Authorized Individual’s Signature 8.b. Date of Signature (mm/dd/yyyy)
NOTE TO ALL REGIONAL CENTERS AND AUTHORIZED INDIVIDUALS: If you do not completely fill out this form or fail to submit required documents listed in the Instructions, USCIS may reject your form. 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.
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[page 6]
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 Email Address (if any)
Interpreter's Certification
I certify that:
I am fluent in English and [fillable box], which is the same language provided in Part 8., Item Number 1.b.;
I have read to the authorized individual of the regional center every question and instruction on this supplement, as well as the answer to every question, in the language provided in Part 8., Item Number 1.b.; and
[page 7]
The authorized individual of the regional center has informed me that he or she understands every instruction and question on the supplement, as well as the answer to every question, and the authorized individual of the regional center verified the accuracy of every answer.
Interpreter's Signature
6.a.
Interpreter's Signature
6.b. Date of Signature (mm/dd/yyyy)
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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 am fluent in English and ___________, which is the same language provided in Part 8., Item Number 1.b., and I have read to the authorized individual in the identified language every question and instruction on this form and his or her answer to every question. The authorized individual informed me that he or she understands every instruction, question, and answer on the form, including the Authorized 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)
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[page 7]
Part 10. Contact Information, Statement, Certification, and Signature of the Person Preparing this Supplement, If Other Than the Authorized Individual of the Regional Center
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
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 Fax Number
6. Preparer's Email Address (if any)
Preparer's Statement
7.a. I am not an attorney or accredited representative but have prepared this supplement on behalf of the authorized individual of the regional center and with the authorized individual's consent.
7.b. I am an attorney or accredited representative and my representation of the authorized individual of the regional center extends/does not extend beyond the preparation of this supplement.
NOTE: If you are an attorney or accredited representative whose representation extends beyond preparation of this supplement, you must submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, with this application.
Preparer's Certification
By my signature, I certify, swear, or affirm, under penalty of perjury, that I prepared this supplement on behalf of, at the request of, and with the express consent of the authorized individual of the regional center. I completed this supplement based only on responses the authorized individual of the regional center provided to me. After completing the supplement, I reviewed it and all of the responses with the authorized individual of the regional center, who agreed with each and every answer on the supplement. If the authorized individual of the regional center supplied additional information concerning a question on the supplement, I recorded it on the supplement.
Preparer's Signature
8.a. Preparer's Signature 8.b. Date of Signature (mm/dd/yyyy)
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Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Form, if Other Than the Authorized 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 form on behalf of the authorized individual and with the authorized individual's consent.
7.b. I am an attorney or accredited representative and have prepared this form on behalf of the authorized individual and with the authorized individual’s consent.
NOTE: If you are an attorney or accredited representative, you may be obliged to submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, with this form.
Preparer's Certification
By my signature, I certify, under penalty of perjury, that I prepared this form at the request of the authorized individual. The authorized individual has reviewed this completed form, including the Authorized 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)
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[page 8]
Part 11. Additional Information
If you need extra space to provide any additional information within this supplement, 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 your supplement or attach a separate sheet of paper. Include 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. __________
7.a. Page Number 7.b. Part Number 7.c. Item Number 7.d. __________
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Part 11. Additional Information
If you need extra space to provide any additional information within this form, 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 form 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. __________
7.a. Page Number 7.b. Part Number 7.c. Item Number 7.d. __________
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Mulvihill, Timothy R |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |