TABLE OF CHANGES - FORM
FORM I-924A, Annual Certification of Regional Center
OMB Number: 1615-0061
Reason for Revision: Revisions to Form I-924A are required to enhance adjudications and improve program integrity. The form and instructions have been reformatted and standard language and new signature sections have been incorporated. |
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[Page 1]
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.
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Page 1, Part 3. Information About the Regional Center
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[Page 1]
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: State: Zip Code:
Web site Address: Fax Number (include area code): Telephone (include area code):
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[Page 1]
Part 1. Information About the Regional Center
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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.
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Page 1, Part 3. Information About the Regional Center
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[Page 1]
B. Name of Managing Company/Agency:
Street Address/P.O. Box:
City: State: Zip Code:
Web site Address: Fax Number (include area code): Telephone (include area code):
C. Name of Other Agent: Street Address/P.O. Box: City: State: Zip Code: Web site Address: Fax Number (include area code): Telephone Number (include area code):
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[Page 1]
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 (with area code) 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.
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Page 1, Part 2. Application Type |
Part 2. Application Type
(check 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) |
[Page 2]
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).
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Page 1, Part 1. Information About Principal of the Regional Center
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[Page 1]
Part 1. Information About Principal of the Regional Center
Name: Last First Middle
Date of Birth (mm/dd/yyyy):
In Care Of: Street Address/P.O. Box:
City: State: Zip Code:
Telephone Number (include area code): Fax 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)
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[Page 2]
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.a. Persons Having Ownership, Control or Beneficial Interest in the Entity Listed in Part 4., Item Number 7.
9.b. Date of Birth (mm/dd/yyyy)
9.c. Country of Birth
9.d. Percentage of Ownership in the Entity Listed in Part 4., Item Number 7. %
9.e. 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)
10.a. Family Name (Last Name) 10.b. Given Name (First Name) 10.c. Middle Name
11. 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 12.a. In Care Of Name (if any) 12.b. Street Number and Name or PO Box 12.c. Apt. Ste. Flr. 12.d. City or Town 12.e. State 12.f. ZIP Code 12.g. Province 12.h. Postal Code 12.i. Country
Contact Information for the Principal Owner of the Regional Center Entity 13. Daytime Telephone Number 14. Fax Number
[Page 3]
15. Email Address (if any) 16. Website Address (if any) [Deleted]
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. - 11.
17.a. Family Name (Last Name) 17.b. Given Name (First Name) 17.c. Middle Name
18. Date of Birth (mm/dd/yyyy) 19. Country of Birth 20. U.S. Social Security Number (if any)
21. Position Held Within the Regional Center Entity
22. Entity Name (for a principal of the Regional Center Entity that is an entity or organization)
23. Federal Employer Identification Number (for a principal of the Regional Center Entity that is an entity or organization)
24.a. Persons Having Ownership, Control, or Beneficial Interest in the Entity Listed in Part 4., Item Number 26.
24.b. Date of Birth (mm/dd/yyyy)
24.c. Country of Birth
24.d. Percentage of Ownership in the Entity Listed in Part 4., Item Number 26. %
24.e. Position Held (if any) in the Entity Listed in Part 4., Item Number 26.
Other Names Used By the Principal Non-Owner of the Regional Center Entity (if applicable)
25.a. Family Name (Last Name) 25.b. Given Name (First Name) 25.c. Middle Name 26. Trade Name (DBA if any) (for the entity listed in Part 4., Item Number 26.
Mailing Address for the Principal Non-Owner of the Regional Center Entity 27.a. In Care Of Name (if any) 27.b. Street Number and Name or PO Box 27.c. Apt. Ste. Flr. 27.d. City or Town 27.e. State 27.f. ZIP Code 27.g. Province 27.h. Postal Code 27.i. Country
Contact Information for the Principal Non-Owner of the Regional Center Entity 28. Daytime Telephone Number 29. Fax Number 30. Email Address (if any) 31. Website Address (if any)
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Page 2, Part 3. Information About the Regional Center
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[Page2]
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 Direct and Indirect Job Creation
Aggregate Jobs Maintained
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:
NAICS Code for the Industry Category
Aggregate EB-5 Capital Investment:
Aggregate Direct and Indirect Job Creation:
Aggregate Jobs Maintained:
b. Industry Category Title:
NAICS Code for the Industry Category
Aggregate EB-5 Capital Investment:
Aggregate Direct and Indirect Job Creation:
Aggregate Jobs Maintained:
c. Industry Category Title: NAICS Code for the Industry Category Aggregate EB-5 Capital Investment: Aggregate Direct and Indirect Job Creation: Aggregate Jobs Maintained:
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[Page 4]
Part 5. Information About the Regional Center’s Operations
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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
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Page 2-6, Part 3. Information About the Regional Center
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[Page 2]
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: Zip Code:
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?
[Page 3]
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.
(1) Business Name:
Industry Category Title:
Address
(Street Number and Name):
City: State: Zip Code:
EB-5 Capital Investment:
Direct and Indirect Job Creation:
Jobs Maintained:
(2) Business Name Industry Category Title: Address (Street Number and Name): City: State: Zip Code: EB-5 Capital Investment: Direct and Indirect Job Creation: Jobs Maintained:
b. Name of Commercial Enterprise: Industry Category Title: Address (Street Number and Name): City: State: Zip Code: 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?
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.
(1) Business Name: Industry Category Title: Address (Street Number and Name): City: State: Zip Code EB-5 Capital Investment Direct and Indirect Job Creation Jobs Maintained
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(2) Business Name: Industry Category Title: Address (Street Number and Name): City: State: Zip Code EB-5 Capital Investment Direct and Indirect Job Creation Jobs Maintained
c. Name of Commercial Enterprise: Industry Category Title: Address (Street Number and Name): City: State: Zip Code: 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?
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.
(1) Business Name: Industry Category Title: Address (Street Number and Name): City: State: Zip Code EB-5 Capital Investment Direct and Indirect Job Creation Jobs Maintained
(2) Business Name: Industry Category Title: Address (Street Number and Name): City: State: Zip Code EB-5 Capital Investment Direct and Indirect Job Creation Jobs Maintained
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d. Name of Commercial Enterprise: Industry Category Title: Address (Street Number and Name): City: State: Zip Code: 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?
[Page 6]
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.
(1) Business Name: Industry Category Title: Address (Street Number and Name): City: State: Zip Code EB-5 Capital Investment Direct and Indirect Job Creation Jobs Maintained
(2) Business Name: Industry Category Title: Address (Street Number and Name): City: State: Zip Code EB-5 Capital Investment Direct and Indirect Job Creation Jobs Maintained
e. Name of Commercial Enterprise: Industry Category Title: Address (Street Number and Name): City: State: Zip Code: 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?
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.
(1) Business Name: Industry Category Title: Address (Street Number and Name): City: State: Zip Code EB-5 Capital Investment Direct and Indirect Job Creation Jobs Maintained
(2) Business Name: Industry Category Title: Address (Street Number and Name): City: State: Zip Code EB-5 Capital Investment Direct and Indirect Job Creation Jobs Maintained
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[Page 4]
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 [Deleted] 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
[Page 5]
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 Investments 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?
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.
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Page 6, Part 3. Information About the Regional Center
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[Page 6]
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.
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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.
[Page 6]
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 [Deleted]
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Page 7, Part 4. Applicant Signature |
[Page 7]
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 complete Part 5.
Printed Name of Applicant
Relationship to the Regional Center Entity (Managing Member, President, CEO, etc.)
Daytime Phone Number (Area/Country Codes)
E-Mail Address
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 Date (mm/dd/yyyy)
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[Page 6]
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 [fillable field], 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., [fillable field], 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.
[Page 7]
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 7]
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 [fillable field], 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 6, Part 5. Signature of Person Preparing This Form, If Other Than Above (Sign Below)
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Part 5. Signature of Person Preparing This Form, If Other Than Above (Sign Below)
Printed Name of Preparer
Firm Name and
Address
Daytime Phone Number (Area/Country Codes) Fax Number (Area/Country Codes)
E-Mail Address
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 Date (mm/dd/yyyy) |
[Page7]
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)
[Page 8]
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
[Deleted] 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 my representation of the authorized individual in this case extends/does not extend beyond the preparation of this form.
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.
[Deleted]
Preparer’s Signature 8.a. Preparer’s Signature 8.b. Date of Signature (mm/dd/yyyy)
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[Page 9]
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 |
| File Title | TABLE OF CHANGE – FORM I-687 |
| Author | jdimpera |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |