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pdfUSCIS
Form I-924A
Annual Certification of Regional Center
Department of Homeland Security
U.S. Citizenship and Immigration Services
To be completed
by an attorney or
BIA-accredited
representative (if any).
Select box if Form
G-28 is attached.
Attorney State Bar Number
(if applicable)
OMB No. 1615-0061
Expires 12/31/2018
Attorney or Accredited Representative
USCIS Online Account Number (if any)
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
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.
4.
Name of Managing Company or Agency
Regional Center Receipt Number
Managing Company or Agency Mailing Address
Regional Center Mailing Address
(USPS ZIP Code Lookup)
2.a. In Care Of Name (if any)
5.a. In Care Of Name (if any)
2.b. Street Number and
Name or PO Box
5.b. Street Number and
Name or PO Box
5.c.
Apt.
2.c.
Ste.
Flr.
Apt.
Flr.
2.d. City or Town
2.e. State
5.d. City or Town
Ste.
2.f.
ZIP Code
(USPS ZIP Code Lookup)
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)
Form I-924A 12/23/16
Contact Information for Managing Company or
Agency
3.
Daytime Telephone Number
4.
Fax Number
5.
Email Address (if any)
6.
Website Address (if any)
Page 1 of 10
Part 2. Information About the Managing
Company or Agency (if different from regional
center entity) (continued)
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.
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.
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Part 3. Reporting Period for Regional Center
Activity
9.b. Date of Birth (mm/dd/yyyy)
Select only one box.
9.c. Country of Birth
1.
Reporting for the Federal fiscal year ending
September 30,
2.
(yyyy).
9.d. Percentage of Ownership in the Entity Listed in Part 4.,
Item Number 7.
%
Reporting for a series of Federal fiscal years
beginning October 1,
September 30,
(yyyy) and ending
9.e. Position Held (if any) in the Entity Listed in Part 4., Item
Number 7.
(yyyy).
Part 4. Information About the Organizational
Structure, Ownership, and Control of Regional
Center Entity
Other Names Used By the Principal Owner of the
Regional Center Entity (if applicable)
Provide all other names the principal owner has ever used,
including aliases, maiden name, and nicknames. If you need
extra space to complete this section, use the space provided in
Part 11. Additional Information.
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)
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.)
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)
Form I-924A 12/23/16
Page 2 of 10
Part 4. Information About the Organizational
Structure, Ownership, and Control of Regional
Center Entity (continued)
18.
Date of Birth (mm/dd/yyyy)
19.
Country of Birth
Mailing Address for the Principal Owner of the
Regional Center Entity
20.
U.S. Social Security Number (if any)
►
12.a. In Care Of Name (if any)
21.
Position Held Within the Regional Center Entity
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12.b. Street Number and
Name or PO Box
12.c.
Apt.
Ste.
12.d. City or Town
12.e. State
12.g. Province
12.h. Postal Code
12.i. Country
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)
Flr.
12.f. ZIP Code
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)
24.c. Country of Birth
Contact Information for the Principal Owner of the
Regional Center Entity
13.
Daytime Telephone Number
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.
14.
Fax Number
15.
Email Address (if any)
Other Names Used By the Principal Non-Owner of
the Regional Center Entity (if applicable)
16.
Website Address (if any)
Provide all other names the principal non-owner has ever used,
including aliases, maiden name, and nicknames. If you need
extra space to complete this section, use the space provided in
Part 11. Additional Information.
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)
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 22.
17.c. Middle Name
Form I-924A 12/23/16
Page 3 of 10
Part 4. Information About the Organizational
Structure, Ownership, and Control of Regional
Center Entity (continued)
2.
Aggregate Non-EB-5 Capital Investment From All
Sponsored Projects
3.
Aggregate Fees Or Other Remittances That Have Been
Paid To The Regional Center Or Any Of Its Principals,
Managing Companies Or Agencies, Or Agents
4.
Aggregate Number of Direct, Indirect, and/or Induced
Jobs Created For All Sponsored Projects
5.
Aggregate Number of Jobs Maintained Through
Investment in Troubled Businesses
Mailing Address for the Principal Non-Owner of
the Regional Center Entity
27.a. In Care Of Name (if any)
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27.b. Street Number and
Name or PO Box
27.c.
Apt.
Ste.
27.d. City or Town
27.e. State
27.g Province
27.h. Postal Code
27.i. Country
Flr.
27.f. ZIP Code
Contact Information for the Principal Non-Owner
of the Regional Center Entity
28.
29.
30.
31.
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.
6.
Name of Industry
7.
North American Industry Classification System (NAICS)
Code for the Industry Category
8.
Aggregate EB-5 Capital Investment
9.
Aggregate Non-EB-5 Capital Investment
10.
Aggregate Number of Direct, Indirect, and/or Induced
Jobs Created
11.
Aggregate Number of Jobs Maintained Through
Investment in Troubled Businesses
12.
Name of Industry
13.
NAICS Code for the Industry Category
14.
Aggregate EB-5 Capital Investment
15.
Aggregate Non-EB-5 Capital Investment
Daytime Telephone Number
Fax Number
Email Address (if any)
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
Form I-924A 12/23/16
Page 4 of 10
Part 5. Information About the Regional Center's
Operations (continued)
16.
Aggregate Number of Direct, Indirect, and/or Induced
Jobs Created
17.
Aggregate Number of Jobs Maintained Through
Investment in Troubled Businesses
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.
2.
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
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Part 6. Information About the New Commercial
Enterprise
1.
5.
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?
Name of the New Commercial Enterprise
New Commercial Enterprise Federal Employer
Identification Number
New Commercial Enterprise Mailing Address
3.a. In Care Of Name (if any)
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
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.
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
4.
Name of Industry Receiving Investment Capital From the
New Commercial Enterprise
Form I-924A 12/23/16
Page 5 of 10
Part 6. Information About the New Commercial
Enterprise (continued)
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.
Mailing Address
14.a. In Care Of Name
14.b. Street Number and
Name or PO Box
14.c.
Apt.
Ste.
14.d. City or Town
14.e. State
Petition By Investor to Remove Conditions (Form
I-829)
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Form I-829 Petition Final Case Actions
Flr.
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.
3.
Name of New Commercial Enterprise
4.
Select only one result.
Approved
Denied
Part 8. Statement, Contact Information,
Certification, and Signature of the Authorized
Individual
NOTE: Read the Penalties section of the Form I-924A
Instructions before completing this section. You must file Form
I-924A while in the United States.
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 every question and instruction on this form
and my answer to every 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
Part 7. Petitions Filed by EB-5 Investors
Immigrant Petition by Alien Investor
(Form I-526)
,
a language in which I am fluent, and I understood all
of this information as interpreted.
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.
2.
NOTE: If an adverse action was ultimately reversed and the
petition was approved, then list the case as approved.
Authorized Individual's Contact Information
Form I-526 Petition Final Case Actions
1.
Name of the New Commercial Enterprise
2.
Select only one result.
Approved
Form I-924A 12/23/16
Denied
At my request, the preparer named in Part 10.,
,
prepared this form for me based only upon information
I provided or authorized.
3.a. Authorized Individual's Family Name (Last Name)
3.b. Authorized Individual's Given Name (First Name)
Revoked
Page 6 of 10
Part 8. Statement, Contact Information,
Certification, and Signature of the Authorized
Individual (continued)
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)
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)
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Authorized Individual's Certification
Copies of any documents submitted are exact photocopies of
unaltered, original documents, and I understand that, as the
authorized 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 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.
If filing this form on behalf of an organization, I certify that I
am authorized to do so by the organization.
I certify, under penalty of perjury, that I provided or authorized
all of the information in my form, I understand all of the
information contained in, and submitted with, my form, and that
all of this information is complete, true, and correct.
Authorized Individual's Signature
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.f.
3.e. ZIP Code
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)
8.a. Authorized Individual's Signature
8.b. Date of Signature (mm/dd/yyyy)
NOTE TO ALL AUTHORIZED INDIVIDUALS: If you do
not completely fill out this form or fail to submit required
documents listed in the Instructions, USCIS may deny your form.
Form I-924A 12/23/16
Page 7 of 10
Part 9. Interpreter's Contact Information,
Certification, and Signature (continued)
Preparer's Mailing Address
3.a. Street Number
and Name
Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and
3.b.
,
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 Certification, and has verified the
accuracy of every answer.
Apt.
Ste.
Flr.
3.c. City or Town
3.d. State
3.e. ZIP Code
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Interpreter's Signature
7.a. Interpreter's Signature
3.f.
Province
3.g. Postal Code
3.h. Country
Preparer's Contact Information
4.
Preparer's Daytime Telephone Number
7.b. Date of Signature (mm/dd/yyyy)
5.
Preparer's Mobile Telephone Number (if any)
Part 10. Contact Information, Declaration, and
Signature of the Person Preparing this Form, if
Other Than the Authorized Individual
6.
Preparer's Email Address (if any)
Provide the following information about the preparer.
Preparer's Statement
Preparer's Full Name
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
1.a. Preparer's Family Name (Last Name)
1.b. Preparer's Given Name (First Name)
preparation of this form.
2.
Preparer's Business or Organization Name (if any)
Form I-924A 12/23/16
NOTE: If you are an attorney or accredited
representative, you may need to submit a completed
Form G-28, Notice of Entry of Appearance as Attorney
or Accredited Representative, with this form.
Page 8 of 10
Part 10. Contact Information, Declaration, and
Signature of the Person Preparing this Form, if
Other Than the Authorized Individual (continued)
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 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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Preparer's Signature
8.a. Preparer's Signature
8.b. Date of Signature (mm/dd/yyyy)
Form I-924A 12/23/16
Page 9 of 10
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.
Name of Regional Center Entity
2.
Regional Center Identification Number
3.b. Part Number
3.c. Item Number
6.a. Page Number
3.d.
5.c. Item Number
5.d.
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1.
3.a. Page Number
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.d.
Form I-924A 12/23/16
4.b. Part Number
4.c. Item Number
7.a. Page Number
7.d.
Page 10 of 10
| File Type | application/pdf |
| File Title | Annual Certification of Regional Center |
| Author | USCIS |
| File Modified | 2019-10-23 |
| File Created | 2019-10-22 |