I-956F Application for Approval of an Investment in a Commercia

Application for Approval of an Investment
in a Commercial Enterprise
Department of Homeland Security
U.S. Citizenship and Immigration Services
Receipt

USCIS
Form I-956F
OMB No. 1615-0159
Expires 07/31/2025

Action Block

G-28

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For
USCIS
Use
Only

To be completed
Select this box if Attorney State Bar Number
by an Attorney or
(if applicable)
Accredited Representative Form G-28 is
attached to represent
of the Regional Center
the Regional Center
(if any).

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

Are you the attorney of record for this Regional Center?

Yes

No

If you answered "No," should U.S. Citizenship and Immigration Services (USCIS) list you as the attorney of
record for correspondence with the Regional Center on all immigration matters?

Yes

No

► START HERE - Type or print in black ink.

Part 1. Application Type
1.

Select whether the application is an Initial Application Form I-956F, for Approval of an Investment in a Commercial
Enterprise, or an Amendment to an already approved Form I-956F:
Initial Form I-956F, Application for Approval of an Investment in a Commercial Enterprise
Amendment to a Previously Approved Form I-956F

2.

If your application is an amendment, provide the receipt number of the approved Form I-956F.

3.

If your application is an amendment, provide the NCE Identification Number (NCEID).

4.

Is the project or offering described in this application the same project or offering submitted with an
approved Form I-924 application or amendment as an exemplar Form I-526 prior to March 15, 2022?

5.

If you answered "Yes," provide the receipt number of the Form I-924. Date of Approval (mm/dd/yyyy)

Yes

No

Part 2. Information About the Regional Center
1.

Legal Name of Regional Center Entity

2.

Regional Center Identification Number

Form I-956F Edition 07/24/23

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Part 2. Information About the Regional Center (continued)
Regional Center Mailing Address (and Physical Address when Applicable)
Mailing Address same as Physical Address
3.

Mailing Address
In Care Of Name (if any)

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Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Part 3. Information About the New Commercial Enterprise (NCE)
1.

Legal Name of the NCE (Required Field - Do Not Leave Blank)

2.

Other Name(s) the NCE is Authorized to Use or Do Business As (d/b/a)

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 14. Additional Information.
Corporation

Partnership (including Limited Parternships)
Limited Liability Company (LLC)

Other (Describe below. If you need extra space to complete this section, use the space provided in Part 14. Additional
Information.)

4.

Is the NCE comprised of a holding company and its wholly owned subsidiaries?

Yes

No

If yes, describe the overall organization structure of the NCE and list each wholly owned subsidiary along with its date and
jurisdiction of formation. If you need additional space, us the space provided in Part 14. Additional Information.
Subsidiary Name

5.

Date of Formation

Jurisdiction of Formation

Date the NCE was Established (mm/dd/yyyy)

Form I-956F Edition 07/24/23

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Part 3. Information About the New Commercial Enterprise (NCE) (continued)
6.

State or Territory Where the NCE was Established

7.

Other States or Territories where the NCE is Registered to do Business

8.

NCE Federal Employer Identification Number (if any)

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NCE Mailing Address (and Physical Address when Applicable)
Mailing Address same as Physical Address
9.

In Care Of Name (if any)

Street Number and Name

City or Town

Apt. Ste. Flr. Number

State

County

ZIP Code

NCE Contact Information
10.

Telephone Number

12.

Website Address (if any)

11.

Email Address (if any)

Address and Census Tract(s) Where the NCE Is Principally Doing Business (Project Location; See
Instructions)
13.

Apt. Ste. Flr. Number

Street Number and Name

City or Town

County

State

ZIP Code

Census Tract(s)

Type of NCE (Select only one)
14.

NCE formed after November 29, 1990.

15.

NCE resulting from the purchase of a business formed on or before November 29, 1990, that is restructured or reorganized.

16.

NCE resulting from a capital investment in, and substantial expansion of, a business formed on or before November 29, 1990.

17.

Is the NCE a troubled business?

Yes

No

NOTE: If you answered “Yes” to Item Number 17., you must provide an explanation in Part 14. Additional Information of how
the NCE qualifies as a troubled business.

Form I-956F Edition 07/24/23

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Part 4. Information about the Job Creating Entity(ies) (JCE)
Provide the information below for the JCE associated with the investment project if different than the NCE. If the regional center
seeks to add more than one JCE with this filing, provide the information below for each JCE in Part 14. Additional Information.
1.

Legal Name of the JCE

2.

Other Name(s) the Entity JCE is Authorized to Use or Do Business As (d/b/a).

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 14. Additional Information.
Corporation

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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 14. Additional
Information.)

4.

Is the JCE compromised of a holding company and its wholly owned subsidiaries?

Yes

No

If you answered "Yes," describe the overall organizational structure of the JCE and list each wholly owned subsidiary along
with its date and jurisdiction of formation. If you need extra space, use the space provided in Part 14. Additional Information.
Subsidiary Name

5.

Date the JCE was Established (mm/dd/yyyy)

6.

State or Territory Where the JCE was Formed

7.

Other States or Territories where the JCE is Registered

8.

JCE Federal Employer Identification Number (if any)

Form I-956F Edition 07/24/23

Date of Formation

Jurisdiction of Formation

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Part 4. Information about the Job Creating Entity(ies) (JCE) (continued)
JCE Mailing Address (and Physical Address when Applicable)
Mailing Address same as Physical Address
9.

In Care Of Name (if any)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

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ZIP Code

JCE Contact Information
10.

Telephone Number

12.

Website Address (if any)

13.

Is the JCE an affiliated JCE? The term "affiliated job-creating entity" means any job-creating entity that is
controlled, managed, or owned by any of the people involved with the regional center or new commercial
enterprise under the Immigration and Nationality Act (INA) section 203(b)(5)(H)(v).

11.

Email Address (if any)

Yes

No

Part 5. Information about the Project

You must provide a comprehensive business plan for a specific capital investment project as well as a credible economic analysis
regarding estimated job creation that is based upon economically and statistically valid and transparent methodologies.
For Item Numbers 1. - 5., select the appropriate box to indicate the type of investment for this project (Select all that apply).
1.

Rural Area

This project is based on an investment in a rural area.
A.

Is the NCE principally doing business in an area outside a metropolitan statistical area (as designated
by the Director of the Office of Management and Budget (OMB))?

Yes

No

B.

Is the NCE principally doing business in an area outside the outer boundary of a city or town having a
population of 20,000 or more (based on the most recent decennial census of the United States)?

Yes

No

High Unemployment Area

2.

This project is based on an investment in a high unemployment area.
A.

In addition to the census tract(s) where the NCE is principally doing business identified in Part 3., Item Number 13., list
any other directly adjacent census tract(s) that you are requesting to be included in designation as an area of high
unemployment (Enter the 11-digit FIPS codes)

Form I-956F Edition 07/24/23

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Part 5. Information about the Project (continued)
B.

What is the weighted average of the unemployment rate for the census tracts you are requesting to be ►
designated as an area of high unemployment, based on the labor force unemployment measure for
each applicable census tract?

C.

What is the national average unemployment rate on the filing date of this application?

D.

What data source(s) and time frames did you use to calculate the unemployment rate for the applicable census tract(s) and
the national average unemployment rate?

3.

►

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Infrastructure Project

This project is based on an investment in an infrastructure project.

4.

A.

Is the project administered by a governmental entity (such as a Federal, state, or local agency or
authority) that is the JCE contracting with the RCE or NCE to receive capital investment under the
regional center program?

Yes

No

B.

Is the project financing for maintaining, improving, or constructing a public works project?

Yes

No

High Employment Area

This project is based on an investment in a high employment area.
5.

Non-TEA/Non-Infrastructure/Non-High Employment

This project is based on an investment that is not an infrastructure project or in an area that is not in a targeted employment
area or high employment area.
6.

Total Estimated Cost of the Project

►$

7.

Number of Expected EB-5 Investors into the NCE

►

8.

Aggregate Amount of Project Costs Funded by EB-5 Capital

►$

9.

Nature of Activity of Project (for example, furniture manufacturer)

10.

Primary Included Industries for Project (provide North American Industry Classification System (NAICS) codes)

11.

Total number of estimated jobs to be created by the project. If available, provide a list of NAICS codes,
industry names, and associated total number of claimed jobs to be created by the investment project.
NAICS Code

►

Claimed Jobs to be Created
by Investment Project

Industry Name

Total

Form I-956F Edition 07/24/23

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Part 6. Investment and Offering Documents
1.

You must include any documents filed with the Securities and Exchange Commission under the Securities Act of 1933 (15
U.S.C. 77a et. seq.) or with the securities regulator of any state, as required by law.
Identify the documentation provided (exhibit number, name of document, filing information).

2.

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You must include all investment and offering documents, including subscription, investment, partnership, and operating
agreements, private placement memoranda, term sheets, biographies of management, officers, directors, and any person with
similar responsibilities, the description of the business plan, and marketing materials used, or drafts prepared for use, in
connection with the offering.
Identify the documentation provided (exhibit number, name of document).

3.

Have all material investment risks associated with the NCE and the JCE been disclosed?

Yes

No

Yes

No

Identify the documents containing this information (exhibit number, name of document, page number).

4.

Are there any conflicts of interest that currently exist or may arise among the regional center, the NCE and
JCE, or the principals, attorneys, or individuals responsible for recruitment or promotion of such entities?

If you answered "Yes," identify any documents containing this information (exhibit number, name of document, page number).

5.

Are there any pending material litigation or bankruptcy, or material adverse judgments or bankruptcy
orders issued during the most recent 10-year period, in the United States or in another country, affecting the
regional center, the NCE, the JCE, or any other enterprise in which any principal of any of the
aforementioned entities held majority ownership at the time?

Yes

No

Yes

No

Identify any documents containing this information (exhibit number, name of document, page number).

6.

Are there any fees, ongoing interest, or other compensation paid, or to be paid by the regional center, the
NCE, or any issuer of securities intended to be offered to alien investors, to agents, finders, or broker
dealers involved in the offering of securities to alien investors in connection with the investment?

Form I-956F Edition 07/24/23

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Part 6. Investment and Offering Documents (continued)
Identify any documents containing this information as well as a description of the services performed, or that will be performed,
by such person to entitle the person to such fees, interest, or compensation and the name and contact information of any such
person, if known at the time of filing (exhibit number, name of document, page number).

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Part 7. Policies and Procedures to Monitor the Issuance of Securities

You must describe the policies and procedures, such as those related to internal and external due diligence, reasonably designed to
cause the new commercial enterprise, job-creating entity, and any issuer of securities to be offered to investors in connection with the
capital investment project, to comply with securities laws of the United States and the applicable states in connection with the offer,
purchase, or sale of securities.
1.

Have you submitted any documentation describing the policies and procedures in place reasonably
designed to monitor the regional center and any issuer of securities to ensure compliance with all applicable
laws?

Yes

No

If you answered "Yes," please describe the documentation provided (exhibit number and/or name of document).

If you answered "No," please describe the policies and procedures in the space provided. If you need extra space to complete
this section, use the space provided in Part 14. Additional Information.

Part 8. Required Certifications

This section must be completed by a qualified certifier for the regional center and any issuer of securities intended to be offered to
alien investors in connection with the capital investment project described in this application. A qualified certifier is a person in a
position of substantive authority for the management or operations of the regional center or issuer of securities, as applicable, such as
a principal executive officer or principal financial officer, with knowledge of such entity's policies and procedures related to
compliance with the requirements under INA section 203(b)(5).

Certification by Regional Center
Regional Center Certifier's Contact Information
1.

Certifier's Family Name (Last Name)

Certifier's Given Name (First Name)

2.

Certifier's Title

3.

Certifier's Daytime Telephone Number

4.

Certifier's Mobile Telephone Number (if any)

5.

Certifier's Email Address (if any)

Form I-956F Edition 07/24/23

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Part 8. Required Certifications (continued)
I certify, under penalty of perjury, that, to the best of my knowledge, after a due diligence investigation, that the agents and employees
of the regional center, and any parties associated with the regional center are in compliance with the securities laws of the United
States and the laws of the applicable states in connection with the offer, purchase, or sale of securities intended to be offered to alien
investors in connection with the capital investment project described in this application.

Certifier’s Signature
6.

Certifier's Signature

Date of Signature (mm/dd/yyyy)

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Certification by Issuer of Securities

Issuer of Securities Certifier's Contact Information
7.

Name of Issuer of Securities

8.

Certifier's Family Name (Last Name)

Certifier's Given Name (First Name)

9.

Certifier's Title

10.

Certifier's Daytime Telephone Number

11.

Certifier's Mobile Telephone Number (if any)

12.

Certifier's Email Address (if any)

I certify, under penalty of perjury, that, to the best of my knowledge, after a due diligence investigation, that the agents and employees
of the issuer of securities named above, and any parties associated with such issuer of securities are in compliance with the securities
laws of the United States and the laws of the applicable states in connection with the offer, purchase, or sale of its securities.

Certifier’s Signature
13.

Certifier's Signature

Date of Signature (mm/dd/yyyy)

Part 9. Information About All Persons Involved with the NCE and Affiliated JCE
You must identify and provide required attestations and information for all persons involved with the NCE and affiliated JCE.
A person involved with an NCE or affiliated JCE includes any person, directly or indirectly, in a position of substantive authority to
make operational or managerial decisions over pooling, securitization, investment, release, acceptance, or control or use of any EB-5
capital from immigrant investors. An individual may be in a position of substantive authority if the person serves as a principal, a
representative, an administrator, an owner, an officer, a board member, a manager, an executive, a general partner, a fiduciary, an
agent, or in a similar position at the NCE or JCE, respectively.

Form I-956F Edition 07/24/23

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Part 9. Information About All Persons Involved with the NCE and Affiliated JCE (continued)
Persons Involved with NCE
1.

Provide the names of all persons involved with the NCE. For any person involved with the NCE indirectly through their
position or other interest in a legal entity, please describe the organizational structure of their involvement.

2.

Provide the name(s) of all owners of the NCE and the percentage of ownership for each.

3.

Provide the name(s) of all members of the board of directors, managers, or other persons in a similar position of authority with
the NCE.

4.

Provide the name(s) of all executives, officers, or other persons in a similar position of authority with the NCE.

5.

Provide the name(s) of all representatives, fiduciaries, agents, or other persons in a similar position of authority with the NCE.

6.

Provide the names of any other persons involved in the NCE and their position with the NCE.

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Persons Involved with Affiliated JCE
7.

If the JCE is an affiliated JCE, provide the names of all persons involved with the affiliated JCE. For any natural person
involved with the affiliated JCE indirectly through their position or other interest in a legal entity, please describe the
organizational structure of their involvement.

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Part 9. Information About All Persons Involved with the NCE and Affiliated JCE (continued)
8.

Provide the name(s) of all owners of the affiliated JCE and the percentage of ownership for each.

9.

Provide the name(s) of all members of the board of directors, managers, or other persons in a similar position of authority with
the affiliated JCE.

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10.

Provide the name(s) of all executives, officers, or other persons in a similar position of authority with the affiliated JCE.

11.

Provide the name(s) of all representatives, fiduciaries, agents, or other persons in a similar position of authority with the
affiliated JCE.

12.

Provide the names of any other persons involved in the affiliated JCE and their position with the affiliated JCE.

If you need extra space to complete this section or have more than one additional individual to list, use the space provided in Part 14.
Additional Information.
Each person involved with the NCE and affiliated JCE must fill out and submit Supplement Form I-956H, Bona Fides of Persons
Involved with Regional Center Program. Each Supplement Form I-956H must be attached to the Form I-956F, Application for
Approval of Investment in a Commercial Enterprise. Each person submitting a Supplement Form I-956H must answer and comply
with all eligibility questions provided on the supplement.
13.

Provide the total number of Supplement Form I-956H to be submitted:

►

Part 10. Fund Administration
1.

Has the NCE and/or affiliated JCE set up a separate account for the deposit and maintenance of all capital
investment from alien investors for the offering and project described in this application, including amounts
held in escrow?

2.

If you answered "Yes," provide the name of the bank (or other financial institution) and account number for each separate
account set up by the NCE and/or affiliated JCE.

Form I-956F Edition 07/24/23

Yes

No

Page 11 of 17

Part 10. Fund Administration (continued)
3.

Has the NCE and/or affiliated JCE retained a fund administrator to administer all investment capital
deposited and maintained in the separate account(s)?

Yes

No

4.

Is the fund administrator a certified public accountant, attorney, or broker-dealer or investment adviser
registered with the Securities and Exchange Commission?

Yes

No

5.

Provide the full legal name and contact information for the fund administrator.

6.

Provide the title, relevant certification, bar, and/or registration number of the fund administrator.

7.

Is the NCE and/or affiliated JCE controlled by or under common control of an investment adviser or
broker-dealer that is registered with the Securities and Exchange Commission?

Yes

No

8.

Provide the full legal name and contact information for the registered investment advisor or broker-dealer.

9.

Provide the title and registration number of the registered investment advisor or broker-dealer.

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Part 11. Statement, Contact Information, Declaration, and Signature of the Authorized Individual
NOTE: Read the Penalties section of the Form I-956F Instructions before completing this section.

Authorized Individual's Statement
Select the appropriate box to indicate whether you read this application yourself or whether you had an interpreter assist you. If
someone assisted you in completing the application, select the box indicating that you used a preparer.
NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.
1.

2.

Authorized Individual's Statement Regarding the Interpreter
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.

B.

The interpreter named in Part 12. has read to me every question and instruction on this application, and my answer to
every question, in
, a language in which I am fluent, and I understood
everything.

Authorized Individual's Statement Regarding the Preparer
At my request, the preparer named in Part 13.,
prepared this application for me based only upon information I provided or authorized.

Form I-956F Edition 07/24/23

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Part 11. Statement, Contact Information, Declaration, and Signature of the Authorized Individual
(continued)
Authorized Individual's Contact Information
3.

Authorized Individual's Family Name (Last Name)

4.

Authorized Individual's Title

Authorized Individual's Given Name (First Name)

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Provide your daytime telephone number, mobile telephone number (if any), and email address (if any).
5.

Authorized Individual's Daytime Telephone Number

7.

Authorized Individual's Email Address (if any)

6.

Authorized Individual's Mobile Telephone Number (if any)

Authorized Individual's Declaration

Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may
require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any
and all of my records that USCIS may need to determine my eligibility for the immigration benefit that I seek.
I furthermore authorize the release of information contained in this application, in supporting documents, in my USCIS records, and in
the organization's records, to other entities and persons where necessary for the administration and enforcement of U.S. immigration
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 audits and on-site visits, as authorized by
8 U.S.C. sections 1103, 1155, and 1184; the EB-5, Reform and Integrity Act of 2022, Div. BB of the Consolidated Appropriations Act,
2022 (Pub. L. No. 117-103); and 8 CFR parts 103, 204, 205, and 214. I further acknowledge that I am aware all regional centers under
the EB-5 Program will be subject to an audit by Department of Homeland Security (DHS) at least once within 5 years and the regional
center is required to make and preserve all documents relevant to the audit as authorized under INA section 203(b)(5)(E)(vii).
I understand that USCIS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or
signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that:
1)

I reviewed and provided or authorized all of the information in my application;

2)

I understood all of the information contained in, and submitted with, my application; and

3)

All of this information was complete, true, and correct at the time of filing.

If filing this application on behalf of an organization, I certify that I am authorized to do so by the organization.
I also understand that USCIS may require biometrics, perform criminal record checks, and other background and database checks
with respect to this regional center, and any individuals involved with this entity.
I certify, under penalty of perjury, that I provided or authorized all of the information in my application, I understand all of the
information contained in, and submitted with, my application, and that all of this information is complete, true, and correct.

Authorized Individual's Signature
You must sign and date your application. Every application MUST contain the signature of the authorized individual. A stamped or
typewritten name in place of a signature is not acceptable.
8.

Authorized Individual's Signature

Date of Signature (mm/dd/yyyy)

NOTE TO ALL AUTHORIZED INDIVIDUALS: If you do not completely fill out this application or fail to submit required
documents listed in the Instructions, USCIS may deny the underlying application and any related or underlying benefit.

Form I-956F Edition 07/24/23

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Part 12. Interpreter's Contact Information, Certification, and Signature
If you used anyone as an interpreter to read the Instructions and questions on this application to you in a language in which you are
fluent, the interpreter must fill out this section.

Interpreter’s Full Name
1.

Interpreter's Family Name (Last Name)

Interpreter's Given Name (First Name)

2.

Interpreter's Business or Organization Name (if any)

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Interpreter's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

6.

Interpreter's Email Address (if any)

5.

Interpreter's Mobile Telephone Number (if any)

Interpreter's Certification

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

, which is the same language specified in

Part 11., Item B. in Item Number 1., 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 has
verified the accuracy of every answer.

Interpreter's Signature
The interpreter must sign and date the application.
7.

Interpreter's Signature

Form I-956F Edition 07/24/23

Date of Signature (mm/dd/yyyy)

Page 14 of 17

Part 13. Contact Information, Declaration, and Signature of the Person Preparing this Application, if
Other Than the Authorized Individual
Provide the following information about the preparer. If the same individual acted as your interpreter and your preparer, that person
should complete both Part 12. and Part 13.

Preparer's Full Name
1.

Preparer's Family Name (Last Name)

Preparer's Given Name (First Name)

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If the person who completed this application is associated with a business or organization, that person should complete the business or
organization name and address information.
2.

Preparer's Business or Organization Name (if any)

Preparer's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

6.

Preparer's Email Address (if any)

5.

Preparer's Mobile Telephone Number (if any)

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.

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 also 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 then reviewed this completed application and informed me that he or she understands all of
the information contained in, and submitted with his or her application, including the Authorized Individual's Declaration, and
informed me that all of the information in the form and in the supporting documents is complete, true, and correct.

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Part 13. Contact Information, Declaration, and Signature of the Person Preparing this Application, if
Other Than the Authorized Individual (continued)
Preparer's Signature
Anyone who helped you complete this application MUST sign and date the application. A stamped or typewritten name in place of a
signature is not acceptable.
8.

Preparer's Signature

Date of Signature (mm/dd/yyyy)

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Part 14. 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.

DRAFT
Not for
Production
10/25/2023

Page Number

B.

Part Number C.

Item Number

Page Number

B.

Part Number C.

Item Number

Page Number

B.

Part Number C.

Item Number

Page Number

B.

Part Number C.

Item Number

D.

4.

A.

D.

5.

A.

D.

6.

A.

D.

Form I-956F Edition 07/24/23

Page 17 of 17