Form I-924A Supplement to Form I-924

USCIS
Form I-924A

Annual Certification of Regional Center
Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-0061
Expires 12/31/2018

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.

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► 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

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)

4.

Regional Center Receipt Number

2.b. Street Number and
Name or PO Box

Regional Center Mailing Address

2.c.

Apt.

2.e. State

5.b. Street Number and
Name or PO Box
Apt.

Ste.

Flr.

5.d. City or Town
5.e. State

5.f.

Flr.

2.d. City or Town

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

5.c.

Ste.

ZIP Code

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)

Regional Center Contact Information
6.

Daytime Telephone Number

7.

Fax Number

8.

Email Address (if any)

9.

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.

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.

Form I-924A 12/23/16 N

Page 1 of 9

Part 3. Reporting Period for Regional Center
Activity

9.b. Date of Birth (mm/dd/yyyy)
9.c. Country of Birth

Select only one box.
1.

Reporting for the Federal fiscal year ending

2.

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

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September 30,

(yyyy).

Reporting for a series of Federal fiscal years
beginning October 1,
September 30,

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

(yyyy) and ending

(yyyy).

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

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

10.a. Family Name
(Last Name)
10.b. Given Name
(First Name)

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)

Date of Birth (mm/dd/yyyy)

3.

Country of Birth

4.

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

5.

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

1.c. Middle Name
2.

10.c. Middle Name

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

Percentage of Ownership of the Regional Center Entity

12.e. State

12.f. ZIP Code

%
6.

Position Held Within the Regional Center Entity (if any)

12.g. Province
12.h. Postal Code

7.

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

12.i. Country

8.

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

Contact Information for the Principal Owner of
the Regional Center Entity

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

Form I-924A 12/23/16 N

13.

Daytime Telephone Number

14.

Fax Number

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Part 4. Information About the Organizational
Structure, Ownership, and Control of Regional
Center Entity (continued)
15.

Email Address (if any)

16.

Website Address (if any)

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)

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25.c. Middle Name
26.

Trade Name (DBA if any) (for the entity listed in Part 4.,
Item Number 22.

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.

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

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

17.a. Family Name
(Last Name)
17.b. Given Name
(First Name)

27.b. Street Number and
Name or PO Box

17.c. Middle Name

27.c.

18.

Date of Birth (mm/dd/yyyy)

27.d. City or Town

19.

Country of Birth

27.e. State

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 22.

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

Apt.

Ste.

Flr.

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)

24.c. Country of Birth

24.d. Percentage of Ownership in the Entity Listed in Part 4.,
Item Number 22.
%
24.e. Position Held (if any) in the Entity Listed in Part 4., Item
Number 22.

Form I-924A 12/23/16 N

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Part 5. Information About the Regional Center's
Operations

11.

Name of Industry

Aggregate Capital Investment and Job Creation

12.

NAICS Code for the Industry Category

Provide the aggregate capital investment and job creation that
has been the focus of the EB-5 capital investments sponsored
through the regional center.

13.

Aggregate EB-5 Capital Investment

14.

Aggregate Non-EB-5 Capital Investment

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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

15.

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

2.

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

16.

Aggregate Number of Jobs Maintained Through
Investment in Troubled Businesses

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

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)

8.

9.

Aggregate Non-EB-5 Capital Investment
3.b. Street Number and
Name or PO Box
Aggregate Number of Direct, Indirect, and/or Induced
Jobs Created

3.c.

Apt.

Ste.

Flr.

3.d. City or Town
10.

Aggregate Number of Jobs Maintained Through
Investment in Troubled Businesses

Form I-924A 12/23/16 N

3.e. State

3.f.

ZIP Code

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Part 6. Information About the New Commercial
Enterprise (continued)

13.

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.

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.

Other Information

14.a. In Care Of Name

4.

5.

Name of Industry

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Name of Industry Receiving Investment Capital From the
New Commercial Enterprise

Mailing Address

14.b. Street Number and
Name or PO Box
14.c.

NAICS Code for the Industry Category

Apt.

Ste.

Flr.

14.d. City or Town

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.

7.

8.

9.

10.

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

Aggregate EB-5 Capital Investment

Aggregate Non-EB-5 Capital Investment

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

Aggregate Number of Jobs Maintained Through
Investments in Troubled Businesses

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

Form I-924A 12/23/16 N

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 Investor
(Form I-526)
Provide the total number of approved, denied, and revoked Form
I-526, Immigrant Petition by Alien Investor, 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 5 of 9

Form I-526 Petition Final Case Actions

Authorized Individual's Contact Information

1.

Name of the New Commercial Enterprise

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

2.

Select only one result.

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

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Approved

Denied

Revoked

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

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)

Form I-829 Petition Final Case Actions
3.

Name of New Commercial Enterprise

4.

Select only one result.
Approved
Denied

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.

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

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.

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

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.

,
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.

Form I-924A 12/23/16 N

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Part 8. Statement, Contact Information,
Declaration, Certification, and Signature of the
Authorized Individual (continued)
Authorized Individual's Signature

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)

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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.

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

Provide the following information about the interpreter.

Interpreter's Full Name

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 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

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

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

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

2.

Interpreter's Business or Organization Name (if any)

Interpreter's Mailing Address

Apt.

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

Flr.

3.c. City or Town
3.d. State

Provide the following information about the preparer.

Preparer's Full Name

3.a. Street Number
and Name
3.b.

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

1.b. Preparer's Given Name (First Name)
3.e. ZIP Code
2.

3.f.

Preparer's Business or Organization Name (if any)

Province

3.g. Postal Code
3.h. Country

Form I-924A 12/23/16 N

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Part 10. Contact Information, Declaration, and
Signature of the Person Preparing this Form, if
Other Than the Authorized Individual (continued)
Preparer's Mailing Address

Apt.

Ste.

Flr.

Preparer's Signature

3.c. City or Town
3.d. State
3.f.

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.

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3.a. Street Number
and Name
3.b.

Preparer's Certification

3.e. ZIP Code

Province

8.a. Preparer's Signature

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

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 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.

Form I-924A 12/23/16 N

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5.a. Page Number

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.

5.c. Item Number

5.d.

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1.

Name of Regional Center Entity

2.

Regional Center Identification Number

3.a. Page Number

3.b. Part Number

3.c. Item Number

6.a. Page Number

3.d.

5.b. Part Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

6.d.

4.a. Page Number

4.b. Part Number

4.c. Item Number
7.a. Page Number

4.d.
7.d.

Form I-924A 12/23/16 N

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