Form I-924 Application for Regional Center Designation Under the Im

Application for Regional Center Designation Under the
Immigrant Investor Program

USCIS
Form I-924
OMB No. 1615-0061
Expires 11/30/2021

Department of Homeland Security
U.S. Citizenship and Immigration Services
Action Block

Do Not Write in This
Block - for USCIS
Use Only (except
G-28 block below)

Fee Receipt
G-28 attached
Attorney's State License Number

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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)

Attorney or Accredited Representative
USCIS Online Account Number (if any)

► START HERE - Type or print in black ink.

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.

3.

Name of Regional Center (if different from regional
center entity)

Regional Center Identification Number

Regional Center Mailing Address
4.a. In Care Of Name (if any)

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

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

Apt.

2.e. State

Ste.

Flr.

4.d. City or Town
4.e. State

4.f.

6.

7.

8.

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)

ZIP Code

Regional Center Contact Information
5.

2.f.

Daytime Telephone Number

Fax Number

Email Address (if any)

Website Address (if any)

Form I-924 Edition 11/21/19

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 of 12

Part 3. Application Type
Select whether the application is an Initial Application or an
Amendment.

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

1.a. Initial Application

Organizational Structure of the Regional Center Entity

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

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.)

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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.

Information About the Principals of the Regional
Center Entity - Owners

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:

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.

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.
Hypothetical
Actual
Actual with I-526 Exemplar

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.

Form I-924 Edition 11/21/19

Date of Birth (mm/dd/yyyy)

Page 2 of 12

12.

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

Trade Name (DBA if any) (for the entity listed in Part 4.,
Item Number 8.)

4.

Country of Birth

Mailing Address for the Owners of the Regional
Center Entity

5.

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

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

6.

Percentage of Ownership in the Regional Center Entity

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%

7.

Position Held Within the Regional Center Entity (if any)

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

Apt.

Ste.

Flr.

13.d. City or Town

8.

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

13.e. State

13.f. ZIP Code

13.g. Province

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.

13.h. Postal Code
13.i. Country

Contact Information for the Owners of the
Regional Center Entity

14.

Daytime Telephone Number

15.

Fax Number

10.d. Percentage of Ownership in the Entity Listed in Part 4.,
Item Number 8.
%

16.

Email Address (if any)

10.e. Position Held (if any) in the Entity Listed in Part 4., Item
Number 8.

17.

Website Address (if any)

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

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. If you need extra space
to complete this section, use the space provided in Part 10.
Additional Information.
11.a. Family Name
(Last Name)
11.b. Given Name
(First Name)
11.c. Middle Name

Biographic Information for the Owners of the
Regional Center Entity
18.

Ethnicity (Select only one box)
Hispanic or Latino

19.

Not Hispanic or Latino

Race (Select all applicable boxes)
White
Asian
Black or African American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander

Form I-924 Edition 11/21/19

Page 3 of 12

Part 4. Information About the Organizational
Structure, Ownership, and Control of the
Regional Center Entity (continued)
20.

Height

Feet

21.

Weight

Pounds

22.

Eye color (Select only one box)
Black
Blue
Brown
Gray
Green

23.

Inches

Black
Blond
Brown
Gray

24.a. Family Name
(Last Name)
24.b. Given Name
(First Name)
24.c. Middle Name
25.

Date of Birth (mm/dd/yyyy)

26.

Country of Birth

27.

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

28.

Position Held Within the Regional Center Entity

29.

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

30.

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

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Hazel

Maroon

Pink

Unknown/Other

Hair color (Select only one box)
Bald (No hair)

Information About the Principal Non-Owner of the
Regional Center Entity

Red

Sandy

White

Unknown/Other

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, any other
names or aliases used, and biographic information. All
principals are required to provide a copy of a valid governmentissued 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, position
held (if any) within the entity or organization, and their
biographic information. For each principal, provide the mailing
address, telephone number, email address, and website address.
If you need extra space to provide information for each person,
use the space provided in Part 10. Additional Information.

Form I-924 Edition 11/21/19

31.a. Persons Having Ownership, Control, or Beneficial
Interest in the Entity Listed in Part 4., Item Number 29.

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

31.d. Percentage Ownership in the Entity Listed in Part 4.,
Item Number 29.
%
31.e. Position Held (if any) in the Entity Listed in Part 4., Item
Number 29.

Page 4 of 12

Part 4. Information About the Organizational
Structure, Ownership, and Control of the
Regional Center Entity (continued)
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. If you need
extra space to complete this section, use the space provided in
Part 10. Additional Information.
32.a. Family Name
(Last Name)
32.b. Given Name
(First Name)

Biographic Information for the Principal NonOwner of the Regional Center Entity
39.

Hispanic or Latino
40.

Not Hispanic or Latino

Race (Select all applicable boxes)
White

Black or African American

American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander

Trade Name (DBA if any) (for the entity listed in Part 4.,
Item Number 29.)

41.

Height

Feet

42.

Weight

Pounds

43.

Eye color (Select only one box)

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

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

Ethnicity (Select only one box)

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Mailing Address For the Principal Non-Owners of
the Regional Center Entity

34.c.

Website Address (if any)

Asian

32.c. Middle Name
33.

38.

Ste.

Inches

Black

Hazel

Blue

Maroon

Brown

Pink

Gray

Unknown/Other

Green

Flr.

44.

Hair color (Select only one box)
Bald (No hair)

Red

Black

Sandy

Blond

White

34.g. Province

Brown

Unknown/Other

34.h. Postal Code

Gray

34.d. City or Town
34.e. State

34.f. ZIP Code

34.i. Country

Contact Information For the Principal
Non-Owners of the Regional Center Entity
35.

Daytime Telephone Number

36.

Fax Number

Information About the Regional Center
45.

Date the Regional Center Entity Was Established
(mm/dd/yyyy)

46.

State or Territory Where the Regional Center Entity Was
Formed

Geographic Area of the Regional Center
47.

37.

Email Address (if any)

Form I-924 Edition 11/21/19

Have you provided a listing of the geographic
components that comprise the limited and contiguous
Yes
No
geographic area of the regional center?

Page 5 of 12

Part 4. Information About the Organizational
Structure, Ownership, and Control of the
Regional Center Entity (continued)
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.
48.

Documentary Evidence of Regional Center
Ownership, Structure, Control and Administration,
Oversight, and Management Functions
53.

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.

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Equity Ledger and/or Capitalization Table

Have you provided a map or other illustration that shows
the geographic area of the regional center?
Yes
No

Organizational Chart

Articles or Certificates of Formation
Partnership Agreement, Operating Agreement, or
Other Governing Documents

NOTE: You will need to provide a map or other
illustration that shows the geographic area of the regional
center.

Meeting Minutes or Written Consents

Have you demonstrated that:

Annual Report

49.

The regional center focuses on a limited, contiguous
geographical area of the United States?
Yes
No

Equity Certificates

50.

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

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.

NOTE: The geographic area covered by the regional
center must be a limited, contiguous, and clearly
identified area.
51.

Regional Center Entity Federal Employer Identification
Number

Promotional Activities
54.

Administration, Oversight, and Management Functions
52.

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
Yes
No
capital investment activities?
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.

Have you submitted documentation, such as a budget, that
details how the regional center has or will conduct
Yes
No
promotional activities?

NOTE: You will need to provide a description and
submit documentation of the regional center's promotional
activities.
Plan of Operation
55.

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
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.

Form I-924 Edition 11/21/19

Page 6 of 12

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

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

USCIS Actions on Prior Form I-924 Approval or Requests
for Designation As a Regional Center
56.

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

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If you answered “Yes” to Item Number 56., 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:
57.

Regional Center Name

58.

Regional Center Identification Number

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)

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.

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

Organizational Structure of the New Commercial
Enterprises
3.

2.

North American Industry Classification System (NAICS)
Code for Included Industry

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

If you answered “No” to Item Number 3., explain in Part 10.
Additional Information.

Form I-924 Edition 11/21/19

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.)

Page 7 of 12

Part 6. Organizational Structure, Ownership,
and Control of Any New Commercial Enterprises
In Which Investors Have Made or Will Make
Their Capital Investments (continued)

12.

Date New Commercial Enterprise Established
(mm/dd/yyyy)

13.

State or Territory Where the New Commercial Enterprise
Was Formed

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.

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14.

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

Documentary Evidence of New Commercial Enterprise
Ownership, Structure, Control and Administration,
Oversight, and Management Functions

5.

Date of Birth (mm/dd/yyyy)

6.

Country of Birth

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)

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 Part 6., Item
Number 9. (if any)

Form I-924 Edition 11/21/19

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.

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 8 of 12

Authorized Individual's Certification

Part 7. Statement, Contact Information,
Certification, and Signature of the Authorized
Individual

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.

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.

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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

If filing this application on behalf of an organization, I certify
that I am authorized to do so by the organization.

,

a language in which I am fluent, and I understood all
of this information as interpreted.
2.

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.

At my request, the preparer named in Part 9.,

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.

,

prepared this application for me based only upon
information I provided or authorized.

Authorized Individual's Signature

8.a. Authorized Individual's Signature

Authorized Individual's Contact Information

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

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

4.

5.

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 deny your application.

Authorized Individual's Title

Authorized Individual's Daytime Telephone Number

Part 8. Interpreter's Contact Information,
Certification, and Signature
Provide the following information about the interpreter.

6.

Authorized Individual's Mobile Telephone Number (if any)

7.

Authorized Individual's Email Address (if any)

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

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

2.

Form I-924 Edition 11/21/19

Interpreter's Business or Organization Name (if any)

Page 9 of 12

Part 8. Interpreter's Contact Information,
Certification, and Signature (continued)

Part 9. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Authorized
Individual

Interpreter's Mailing Address
3.a. Street Number
and Name
3.b.

Apt.

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

Province

3.g. Postal Code
3.h. Country

Provide the following information about the preparer.

Ste.

Preparer's Full Name

Flr.

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

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3.e. ZIP Code

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

2.

Preparer's Business or Organization (if any)

Preparer's Mailing Address

Interpreter's Contact Information

3.a. Street Number
and Name

4.

Interpreter's Daytime Telephone Number

3.b.

5.

Interpreter's Mobile Telephone Number

Apt.

Flr.

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

6.

Ste.

Interpreter's Email Address (if any)

3.f.

3.e. ZIP Code

Province

3.g. Postal Code

Interpreter's Certification

I certify, under penalty of perjury, that:
I am fluent in English and

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.

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)

Interpreter's Signature
7.a. Interpreter's Signature

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

Form I-924 Edition 11/21/19

Page 10 of 12

Part 9. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Authorized
Individual (continue)
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.

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Not for
Production
05/18/2020

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.

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 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)

Form I-924 Edition 11/21/19

Page 11 of 12

5.a. Page Number

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.
Name of the Regional Center Entity

2.

Regional Center Identification Number

3.d.

3.b. Part Number

5.c. Item Number

5.d.

DRAFT
Not for
Production
05/18/2020

1.

3.a. Page Number

5.b. Part Number

3.c. Item Number

6.a. Page 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-924 Edition 11/21/19

Page 12 of 12