Table of Changes (FRM I-924)

TABLE OF CHANGES – FORM

Form I-924, Application for Regional Center Designation Under the Immigrant Investor Program

OMB Number: 1615-0061

10/21/2019

Reason for Revision: This revision includes edits made pursuant to EB-5 Rule.

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Current Page Number and Section	Current Text	Proposed Text
Page 1, To be completed by an attorney or BIA-accredited representative (if any).	[page 1] [new] To be completed by an attorney or BIA-accredited representative (if any). Select box if G-28 is attached to represent the regional center Attorney State Bar Number (if applicable) Attorney or Accredited Representative USCIS Online Account Number (if any) START HERE - Type or print in black ink.	[page 1] Do Not Write in This Block – for USCIS Use Only (except G-28 block below) Action Block Fee Receipt G-28 Attached Attorney’s State License No. [no change] Select box if Form G-28 is attached. [no change]
Page 1, Part 1. Information About the Regional Center	[page 1] Part 1. Information About the Regional Center 1. Name of Regional Center Entity If filing an amendment to a previously approved Form I-924: 2. Name of Regional Center (if different from regional center entity) 3. Regional Center Identification Number Regional Center Mailing Address 4.a. In Care Of Name (if any) 4.b. Street Number and Name or PO Box 4.c. Apt. Ste. Flr. 4.d. City or Town 4.e. State 4.f. ZIP Code Regional Center Contact Information 5. Daytime Telephone Number 6. Fax Number 7. Email Address (if any) 8. Website Address (if any)	[page 1] [no change]
Page 1, Part 2. Information About the Managing Company or Agency (if different from the regional center entity)	[page 1] Part 2. Information About the Managing Company or Agency (if different from the regional center entity) 1. Name of the Managing Company or Agency Managing Company or Agency Mailing Address 2.a. In Care Of Name (if any) 2.b. Street Number and Name or PO Box 2.c. Apt. Ste. Flr. 2.d. City or Town 2.e. State 2.f. ZIP Code Contact Information for Managing Company or Agency 3. Daytime Telephone Number 4. Fax Number 5. Email Address (if any) 6. Website Address (if any) NOTE for Multiple Managing Companies or Agencies: If more than one managing company or agency is associated with the regional center, provide the above information for all other managing companies or agencies in the space provided in Part 10. Additional Information.	[page 1] [no change]
Page 2, Part 3. Application Type	[page 2] Part 3. Application Type Select whether the application is an Initial Application or an Amendment. 1.a. Initial Application Initial application for designation as a regional center. Request to add a new commercial enterprise associated with the regional center. Provide the name of the added new commercial enterprise: 1.b. Amendment Amendment to an approved regional center application. Select the appropriate box below to indicate the type of amendment. Amendment to the regional center's name, organizational structure, ownership, or administration. Amendment to change or modify the geographic area for the regional center. Amendment to change or modify the approved industries of focus for the regional center. Amendment to add a new commercial enterprise associated with the regional center and/or seek a preliminary determination of EB-5 compliance for an exemplar Form I-526, Immigrant Petition by Entrepreneur, for that new commercial enterprise, before individual entrepreneurs file their petitions. Please provide the name of the added new commercial enterprise: Amendment to notify USCIS of changes in the name, organizational structure or administration, capital investment instruments, or offering memoranda (including changes in the economic analysis and underlying business plan used to estimate job creation) for a previously added new commercial enterprise associated with the regional center. 2. Project Type Indicate the type of projects submitted in support of the application. Hypothetical Actual Actual with I-526 Exemplar	[page 2] [no change] Amendment to add a new commercial enterprise associated with the regional center and/or seek a preliminary determination of EB-5 compliance for an exemplar Form I-526, Immigrant Petition by Alien Investor, for that new commercial enterprise, before individual investors file their petitions. Please provide the name of the added new commercial enterprise: Amendment to notify U.S. Citizenship and Immigration Services (USCIS) of changes in the name, organizational structure or administration, capital investment instruments, or offering memoranda (including changes in the economic analysis and underlying business plan used to estimate job creation) for a previously added new commercial enterprise associated with the regional center. 2. Project Type Select the type of projects submitted in support of the application. [no change]
Pages 2-6, Part 4. Information About the Organizational Structure, Ownership, and Control of the Regional Center Entity	[page 2] Part 4.  Information About the Organizational Structure, Ownership, and Control of the Regional Center Entity 1. Organizational Structure of the Regional Center Entity Select the organizational structure. If the organizational structure is different from the examples listed below, select “Other” and describe the nature of the organizational structure. 1.a. Agency of a U.S. state, territory, or local government 1.b. Corporation 1.c. Partnership (including limited partnerships) 1.d. Limited Liability Company (LLC) 1.e. Other (Describe below. If you need extra space to complete this section, use the space provided in Part 10. Additional Information.) Information About the Principals of the Regional Center Entity - Owners List all persons or legal entities or organizations that own or have a percentage of ownership in the regional center entity. For persons, include each owner's name, date of birth, country of birth, U.S. Social Security Number, the percentage of ownership, the position/title held within the regional center (if any), and any other names or aliases used. All such principals are required to provide a copy of a valid government-issued photo identification document and should provide a U.S. Social Security Number. For any owner that is an entity or organization, provide the entity's name, its percentage of ownership, the Federal Employer Identification Number, any trade name (DBA), and list the name of all persons having ownership, control, or a beneficial interest in that entity or organization, their date of birth, country of birth, the percentage of ownership, and the position held (if any) within the entity or organization. For each owner, provide the mailing address, telephone number, email address, and website address. If you need extra space to complete this section, use the space provided in Part 10. Additional Information. Information About the Owners of the Regional Center Entity 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name 3. Date of Birth (mm/dd/yyyy) [page 3] 4. Country of Birth 5. U.S. Social Security Number (if any) 6. Percentage of Ownership in the Regional Center Entity % 7. Position Held Within the Regional Center Entity (if any) 8. Entity Name (for an owner of the Regional Center Entity that is an entity or organization) 9. Federal Employer Identification Number (for an owner of the Regional Center Entity that is an entity or organization) 10.a. Persons Having Ownership, Control, or Beneficial Interest in the Entity Listed in Part 4., Item Number 8. 10.b. Date of Birth (mm/dd/yyyy) 10.c. Country of Birth 10.d. Percentage of Ownership in the Entity Listed in Part 4., Item Number 8. % 10.e. Position Held (if any) in the Entity Listed in Part 4., Item Number 8. Other Names Used By the Owners of the Regional Center Entity (if applicable) Provide all other names the owner has ever used, including aliases, maiden name, and nicknames. 11.a. Family Name (Last Name) 11.b. Given Name (First Name) 11.c. Middle Name 12. Trade Name (DBA if any) (for the entity listed in Part 4., Item Number 8.) Mailing Address for the Owners of the Regional Center Entity 13.a. In Care Of Name (if any) 13.b. Street Number and Name or PO Box 13.c. Apt. Ste. Flr. 13.d. City or Town 13.e. State 13.f. ZIP Code 13.g. Province 13.h. Postal Code 13.i. Country Contact Information for the Owners of the Regional Center Entity 14. Daytime Telephone Number 15. Fax Number 16. Email Address (if any) 17. Website Address (if any) Information About the Principals of the Regional Center Entity - Non-Owners List all principals associated with the regional center, other than those already identified in Part 4., Item Numbers 2.a. - 12. For each person, include the principal non-owner's name, date of birth, country of birth, U.S. Social Security Number, the position/title held within the regional center entity, and any other names or aliases used. All principals are required to provide a copy of a valid government-issued photo identification document and should provide a U.S. Social Security Number. For each principal that is an entity or organization, provide the name of the entity, the Federal Employer Identification Number, any trade name (DBA), and list the names of all persons having ownership, control, or a beneficial interest in that entity or organization, their date of birth, country of birth, the percentage of ownership, and the position held (if any) within the entity or organization. For each principal, provide the mailing address, telephone number, email address, and website address. If you need extra space to complete this section, use the space provided in Part 10. Additional Information. [page 4] Information About the Principal Non-Owner of the Regional Center Entity 18.a. Family Name (Last Name) 18.b. Given Name (First Name) 18.c. Middle Name 19. Date of Birth (mm/dd/yyyy) 20. Country of Birth 21. U.S. Social Security Number (if any) 22. Position Held Within the Regional Center Entity 23. Entity Name (for a principal of the Regional Center Entity that is an entity or organization) 24. Federal Employer Identification Number (for a principal of the Regional Center Entity that is an entity or organization) 25.a. Persons Having Ownership, Control, or Beneficial Interest in the Entity Listed in Part 4., Item Number 23. 25.b. Date of Birth (mm/dd/yyyy) 25.c. Country of Birth 25.d. Percentage Ownership in the Entity Listed in Part 4., Item Number 23. % 25.e. Position Held (if any) in the Entity Listed in Part 4., Item Number 23. Other Names Used By the Principal Non-Owner of the Regional Center Entity (if applicable) Provide all other names the principal non-owner has ever used, including aliases, maiden name, and nicknames. 26.a. Family Name (Last Name) 26.b. Given Name (First Name) 26.c. Middle Name 27. Trade Name (DBA if any) (for the entity listed in Part 4., Item Number 23.) Mailing Address For the Principal Non-Owners of the Regional Center Entity 28.a. In Care Of Name (if any) 28.b. Street Number and Name or PO Box 28.c. Apt. Ste. Flr. 28.d. City or Town 28.e. State 28.f. ZIP Code 28.g. Province 28.h. Postal Code 28.i. Country Contact Information For the Principal Non-Owners of the Regional Center Entity 29. Daytime Telephone Number 30. Fax Number 31. Email Address (if any) 32. Website Address (if any) [page 5] Information About the Regional Center 33. Date the Regional Center Entity Was Established (mm/dd/yyyy) 34. State or Territory Where the Regional Center Entity Was Formed Geographic Area of the Regional Center 35. Have you provided a listing of the geographic components that comprise the limited and contiguous geographic area of the regional center? Yes No NOTE: You will need to provide a listing of the geographic components that comprise the limited geographic area of the regional center. If filing an amendment to expand the geographic area of a regional center, you must describe both the currently approved geographic area and the area of requested expansion, as well as provide documentation that explains the economic rationale for the requested expansion. 36. Have you provided a map or other illustration that shows the geographic area of the regional center? Yes No NOTE: You will need to provide a map or other illustration that shows the geographic area of the regional center. Have you demonstrated that: 37. The regional center focuses on a limited, contiguous geographical area of the United States? Yes No 38. The boundaries are reasonable based on evidence that the proposed area is contributing significantly to the supply chain and labor pool of the proposed new commercial enterprises? Yes No NOTE: The geographic area covered by the regional center must be a limited, contiguous, and clearly identified area. 39. Regional Center Entity Federal Employer Identification Number Administration, Oversight, and Management Functions 40. Have you submitted a plan that demonstrates that there are (or will be) sufficient management, oversight, and administrative functions in place to monitor all EB-5 capital investment activities? Yes No NOTE: You must provide a description and submit documentation of the regional center's administration, oversight, and management functions that are or will be in place to monitor all capital investment activities and the allocation of the jobs created or maintained under its sponsorship. Documentary Evidence of Regional Center Ownership, Structure, Control and Administration, Oversight, and Management Functions 41. Indicate the type of documentation you have submitted to establish the regional center's ownership, structure, control and administration, oversight, and management functions. This list is not exclusive and if you have documentation that is not reflected in the examples listed below, select “Other” and describe the nature of the documentation. Equity Ledger and/or Capitalization Table Organizational Chart Articles or Certificates of Formation Partnership Agreement, Operating Agreement, or Other Governing Documents Meeting Minutes or Written Consents Annual Report Equity Certificates Organizational Information Identifying the Regional Center as a Unit of an Agency or Municipality of a U.S. State or Territory Other (Describe the nature of the documentation below.) If you need extra space to complete this section, use the space provided in Part 10. Additional Information. Promotional Activities 42. Have you submitted documentation, such as a budget, that details how the regional center has or will conduct promotional activities? Yes No NOTE: You will need to provide a description and submit documentation of the regional center's promotional activities. [page 6] Plan of Operation 43. Have you submitted a plan of operation that details how EB-5 investors will be recruited, the methods by which the capital investment opportunities will be offered, and how potential investors will subscribe or commit to the investment? Yes No NOTE: You must provide a description and submit documentation of the regional center's operational plan regarding investor recruitment, the types of investment offerings, and the methods by which the investors will subscribe or otherwise commit to the investments offered. USCIS Actions on Prior Form I-924 Approval or Requests for Designation As a Regional Center 44. Has U.S. Citizenship and Immigration Services (USCIS) ever terminated this regional center's designation; or has the regional center entity, principal, managing company, or agent involved with this application ever been associated with a regional center whose designation was terminated; or has the regional center entity, principal, managing company, or agent involved with this application ever filed Form I-924, Application for Regional Center Designation Under the Immigrant Investor Program, or Form I-924 amendment that was denied? Yes No If you answered “Yes” to Item Number 44., provide an explanation of the denial or termination and/or the association between the regional center principal, managing company, or owner and the denied or terminated regional center in Part 10. Additional Information and the following information associated with the denied or terminated regional center: 45. Regional Center Name 46. Regional Center Identification Number	[page 2] Part 4.  Information About the Organizational Structure, Ownership, and Control of the Regional Center Entity Organizational Structure of the Regional Center Entity [no change] 1.a. Agency of a U.S. State, Territory, or Local Government [no change] Provide all other names the 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 10. Additional Information. [no change] 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 10. Additional Information. [no change] 43. Have you submitted a plan of operation that details how EB-5 investors will be recruited, the methods by which the capital investment opportunities will be offered, how potential investors will subscribe or commit to the investment, how the regional center will conduct investor due diligence, and explains any and all fees or other remittances that will be paid to the regional center or any of its principals, managing companies or agencies, or agents? Yes No [no change] USCIS Actions on Prior Form I-924 Approval or Requests for Designation As a Regional Center 44. Has USCIS ever terminated this regional center's designation; or has the regional center entity, principal, managing company, or agent involved with this application ever been associated with a regional center whose designation was terminated; or has the regional center entity, principal, managing company, or agent involved with this application ever filed Form I-924, Application for Regional Center Designation Under the Immigrant Investor Program, or Form I-924 amendment that was denied? Yes No [no change]
Page 6, Part 5. Information About the Industries That Will Be the Focus of EB-5 Capital Investments Sponsored Through the Regional Center	[page 6] Part 5. Information About the Industries That Will Be the Focus of EB-5 Capital Investments Sponsored Through the Regional Center List each industry that has or will be the focus of EB-5 capital investments sponsored through the regional center. If you need extra space to complete this section, use the space provided in Part 10. Additional Information. 1. Nature of Industry (for example, furniture manufacturer) 2. North American Industry Classification System (NAICS) Code for Included Industry 3. Is Form I-924 supported by an economic analysis and underlying business plan for determining prospective EB-5 job creation through EB-5 investments in this industry category? Yes No If you answered “No” to Item Number 3., explain in Part 10. Additional Information. 4. Nature of Industry (for example, furniture manufacturer) 5. North American Industry Classification System (NAICS) Code for Included Industry 6. Is this Form I-924 supported by an economic analysis and underlying business plan for determining prospective EB-5 job creation through EB-5 investments in this industry category? Yes No If you answered “No” to Item Number 6., explain in Part 10. Additional Information. NOTE: For each additional industry, provide the information requested above in Part 10. Additional Information.	[page 6] [no change] 3. Is this Form I-924 supported by an economic analysis and underlying business plan for determining prospective EB-5 job creation through EB-5 investments in this industry category? Yes No [no change]
Pages 6-8, Part 6. Organizational Structure, Ownership, and Control of Any New Commercial Enterprises In Which Investors Have Made or Will Make Their Capital Investments	[page 6] Part 6. Organizational Structure, Ownership, and Control of Any New Commercial Enterprises In Which Investors Have Made or Will Make Their Capital Investments Provide the information below if the regional center requests to add a new commercial enterprise associated with the regional center or if the regional center requests to amend a previously added new commercial enterprise. If the regional center seeks to add more than one new commercial enterprise with this filing, provide the information below for each new commercial enterprise in Part 10. Additional Information. 1. Name of the New Commercial Enterprise 2. New Commercial Enterprise Federal Employer Identification Number [page 7] Organizational Structure of the New Commercial Enterprises 3. Select the organizational structure. If the organizational structure is different from the examples listed below, select “Other” and describe the nature of the organizational structure in Part 10. Additional Information. Also, if you need additional space to add new commercial enterprises that are established, use Part 10. Additional Information. Corporation Partnership (including limited partnerships) Limited Liability Company (LLC) Other (Describe below. If you need extra space to complete this section, use the space provided in Part 10. Additional Information.) Ownership List and provide the required information for all persons or legal entities or organizations that own or have a percentage of ownership in the new commercial enterprise. Information About the Owner of the New Commercial Enterprise 4.a. Family Name (Last Name) 4.b. Given Name (First Name) 4.c. Middle Name 5. Date of Birth (mm/dd/yyyy) 6. Country of Birth 7. Percentage of Ownership % 8. Position Held Within the New Commercial Enterprise (if any) 9. Entity Name (for an owner that is an entity or organization) 10. Federal Employer Identification Number (for an owner that is an entity or organization) 11.a. Names of Persons Having Ownership, Control, or Beneficial Interest in the Entity Listed in Part 6., Item Number 9. 11.b. Date of Birth (mm/dd/yyyy) 11.c. Country of Birth 11.d. Percentage of Ownership in the Entity Listed in Part 6., Item Number 9. % 11.e. Position Held Within the Entity Listed in Item Number 9. of This Section (if any) 12. Date New Commercial Enterprise Established (mm/dd/yyyy) 13. State or Territory Where the New Commercial Enterprise Was Formed Documentary Evidence of New Commercial Enterprise Ownership, Structure, Control and Administration, Oversight, and Management Functions 14. Indicate the type of documentation you submitted to establish the ownership, structure, control and administration, oversight, and management functions of the new commercial enterprise. If you have documentation that is not reflected in the examples listed below, describe and explain the nature of the organization in Part 10. Additional Information. Equity Ledger and/or Capitalization Table Organizational Chart Articles or Certificates of Formation Governing Document (for example, partnership agreement, operating agreement) Meeting Minutes or Written Consents Annual Report Equity Certificates Other (Describe the nature of the documentation below.) If you need extra space to complete this section, use the space provided in Part 10. Additional Information. [page 8] 15. Does or will the regional center or any of its principals or agents have an equity stake in the new commercial enterprises? Yes No If you answered “Yes” to Item Number 15., provide an explanation in Part 10. Additional Information and submit documentation with this application that details such equity ownership. 16. Does or will the regional center or any of its principals, managing companies, or agents receive fees, profits, surcharges, or other remittances through EB-5 capital investment activities from any current or prospective new commercial enterprise or any current or prospective EB-5 investor (beyond the minimum capital investment threshold required of the EB-5 investors)? Yes No If you answered “Yes” to Item Number 16., provide an explanation in Part 10. Additional Information and submit documentation of the circumstances under which these remittances will be paid.	[page 6] [no change] 11.e. Position Held Within the Entity Listed in Part 6., Item Number 9. (if any) [no change]
Page 8, Part 7. Statement, Contact Information, Declaration, Certification, and Signature of the Authorized Individual	[page 8] Part 7. Statement, Contact Information, Declaration, Certification, and Signature of the Authorized Individual NOTE: Read the Penalties section of the Form I-924 Instructions before completing this part. Authorized Individual's Statement 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 I have read and understand every question and instruction on this application, as well as my answer to every question. 1.b. The interpreter named in Part 8. read to me every question and instruction on this application and my answer to every question, in [Fillable Field], a language in which I am fluent.  I understand all of this information as interpreted. 2. At my request, the preparer named in Part 9., [Fillable Field], prepared this application 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, 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 application using publicly available open source information. I also recognize that any supporting evidence submitted in support of this application may be verified by USCIS through any means determined appropriate by USCIS, including but not limited to, on-site compliance reviews. If filing this application 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 have reviewed this application, I understand all of the information contained in, and submitted with, my application, 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 APPLICANTS AND AUTHORIZED INDIVIDUALS: If you do not completely fill out this application or fail to submit required documents listed in the Instructions, USCIS may delay a decision on or deny your application.	[page 8] Part 7. Statement, Contact Information, Certification, and Signature of the Authorized Individual NOTE: Read the Penalties section of the Form I-924 Instructions before completing this section. [no change] 1.a. I can read and understand English, and I have read and understand every question and instruction on this application and my answer to every question. 1.b. The interpreter named in Part 8. has read to me every question and instruction on this application and my answer to every question in [Fillable Field], a language in which I am fluent, and  I understood all of this information as interpreted. [no change] Authorized Individual's Certification [no change] NOTE TO ALL APPLICANTS AND AUTHORIZED INDIVIDUALS: If you do not completely fill out this application or fail to submit required documents listed in the Instructions, USCIS may deny your application.
Page 9, Part 8. Interpreter's Contact Information, Certification, and Signature	[page 9] Part 8.  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 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 specified in Part 7., Item Number 1.b., and I have read to the authorized individual in the identified language every question and instruction on this application 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 application, 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)	[page 9] [no change] I am fluent in English and [Fillable Field], which is the same language specified in Part 7., Item Number 1.b., and I have read to the authorized individual in the identified language every question and instruction on this application 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 application, including the Authorized Individual's Certification, and has verified the accuracy of every answer. [no change]
Pages 9-10, Part 9. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Authorized Individual	[page 9] Part 9. Contact Information, Declaration, and Signature of the Person Preparing this Application, 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 (if any) NOTE: If applicable, provide the name of your accredited organization recognized by the Board of Immigration Appeals (BIA). 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) [page 10] Preparer's Statement 7.a. I am not an attorney or accredited representative but have prepared this application 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 in this case extends/does not extend beyond the preparation of this application. 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 application. Preparer's Certification By my signature, I certify, under penalty of perjury, that I prepared this application at the request of the authorized individual of the regional center. The authorized individual has reviewed this completed application, 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)	[page 9] [no change] [deleted] [no change] 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 application. [no change] By my signature, I certify, under penalty of perjury, that I prepared this application at the request of the authorized individual of the regional center. The authorized individual has reviewed this completed application, 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. [no change]
Page 11, Part 10. Additional Information	[page 11] Part 10. Additional Information If you need extra space to provide any additional information within this application, 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 application 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 the 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. [new]	[page 11] [no change] 7.a. Page Number 7.b. Part Number 7.c. Item Number 7.d. [Fillable field]

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