Fillable Printable Form I-924

Form I-924

Form I-924 12/23/16 N Page 1 of 11

Select box if G-28 is

attached to represent

the regional center

Application for Regional Center Designation Under the

Immigrant Investor Program

Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS

Form I-924

OMB No. 1615-0061

Expires 12/31/2018

START HERE - Type or print in black ink.►

Part 1. Information About the Regional Center

Name of Regional Center (if different from regional

center entity)

1. Name of Regional Center Entity

3. Regional Center Identification Number

ZIP Code

4.f.

State

City or Town

4.e.

4.d.

Regional Center Mailing Address

4.a.

In Care Of Name (if any)

Street Number and

Name or PO Box

4.b.

4.c. Apt. Flr.Ste.

Regional Center Contact Information

7. Email Address (if any)

Fax Number6.

Daytime Telephone Number5.

8. Website Address (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

ZIP Code

2.f.

State

City or Town

2.e.

2.d.

Managing Company or Agency Mailing Address

2.a.

In Care Of Name (if any)

2.b.

2.c. Apt.

Flr.Ste.

Contact Information for Managing Company or

Agency

5. Email Address (if any)

Fax Number 4.

Daytime Telephone Number 3.

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.

If filing an amendment to a previously approved Form I-924:

To be completed

by an attorney or

BIA-accredited

representative (if any).

Attorney State Bar Number

(if applicable)

Attorney or Accredited Representative

USCIS Online Account Number (if any)

Street Number and

Name or PO Box

Form I-924 12/23/16 N Page 2 of 11

Part 3. Application Type

1.a.

Initial Application

Select whether the application is an Initial Application or an

Amendment.

Request to add a new commercial enterprise

associated with the regional center. Provide the name

of the added new commercial enterprise:

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 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.

Hypothetical

Part 4. Information About the Organizational

Structure, Ownership, and Control 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.

Actual

Actual with I-526 Exemplar

Organizational Structure of the Regional Center

Entity

1.a.

Agency of a U.S. state, territory, or local government

Corporation

1.b.

1.c.

Partnership (including limited partnerships)

1.d.

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.)

1.e.

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.

Amendment to change or modify the approved

industries of focus for the regional center.

Project Type

Amendment

1.b.

Indicate the type of projects submitted in support of the

application.

Initial application for designation as a regional center.

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)

Form I-924 12/23/16 N Page 3 of 11

Part 4. Information About the Organizational

Structure, Ownership, and Control of the

Regional Center Entity (continued)

6. Percentage of Ownership in the Regional Center Entity

Entity Name (for an owner of the Regional Center Entity

that is an entity or organization)

7. Position Held Within the Regional Center Entity (if any)

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.

13.d. City or Town

13.e. State 13.f. ZIP Code

13.g.

Postal Code13.h.

Province

13.i. Country

13.b.

13.c.

Apt. Flr.Ste.

Mailing Address for the Owners of the Regional

Center Entity

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

Contact Information for the Owners of the

Regional Center Entity

16.

Email Address (if any)

Fax Number15.

Daytime Telephone Number14.

17.

Website Address (if any)

Street Number and

Name or PO Box

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

Country of Birth

Other Names Used By the Owners of the Regional

Center Entity (if applicable)

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.)

Provide all other names the owner has ever used, including

aliases, maiden name, and nicknames.

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.

►

Form I-924 12/23/16 N Page 4 of 11

Part 4. Information About the Organizational

Structure, Ownership, and Control of the

Regional Center Entity (continued)

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)

23.

Entity Name (for a principal of the Regional Center Entity

that is an entity or organization)

22.

Position Held Within the Regional Center Entity

24.

Federal Employer Identification Number (for a principal

of the Regional Center Entity that is an entity or

organization)

Other Names Used By the Principal Non-Owner of

the Regional Center Entity (if applicable)

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.)

28.d. City or Town

28.e. State 28.f. ZIP Code

28.g.

Postal Code28.h.

Province

28.i. Country

28.b.

28.c.

Apt. Flr.Ste.

Mailing Address For the Principal Non-Owners of

the Regional Center Entity

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

Street Number and

Name or PO Box

Provide all other names the principal non-owner has ever used,

including aliases, maiden name, and nicknames.

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.e.

Position Held (if any) in the Entity Listed in Part 4., Item

Number 23.

25.d.

Percentage Ownership in the Entity Listed in Part 4.,

Item Number 23.

Contact Information For the Principal

Non-Owners of the Regional Center Entity

Fax Number30.

Daytime Telephone Number29.

31. Email Address (if any)

32. Website Address (if any)

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Form I-924 12/23/16 N Page 5 of 11

Part 4. Information About the Organizational

Structure, Ownership, and Control of the

Regional Center Entity (continued)

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.

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

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

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.

Nature of Industry (for example, furniture manufacturer)

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.

New Commercial Enterprise Federal Employer

Identification Number

Name of the New Commercial Enterprise

Form I-924 12/23/16 N Page 7 of 11

Organizational Structure of the New Commercial

Enterprises

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.

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.

12. Date New Commercial Enterprise Established

(mm/dd/yyyy)

13.

State or Territory Where the New Commercial Enterprise

Was Formed

11.e.

Position Held Within the Entity Listed in Item

Number 9. of This Section (if any)

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

Part 6. Organizational Structure, Ownership,

and Control of Any New Commercial Enterprises

In Which Investors Have Made or Will Make

Their Capital Investments (continued)

5. Date of Birth (mm/dd/yyyy)

Country of Birth

Entity Name (for an owner that is an entity or

organization)

Position Held Within the New Commercial Enterprise (if

any)

7. Percentage of Ownership %

Documentary Evidence of New Commercial Enterprise

Ownership, Structure, Control and Administration,

Oversight, and Management Functions

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.

14.

Form I-924 12/23/16 N Page 8 of 11

Part 6. Organizational Structure, Ownership,

and Control of Any New Commercial Enterprises

In Which Investors Have Made or Will Make

Their Capital Investments (continued)

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.

Authorized Individual's Contact Information

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

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

Authorized Individual's Title4.

Authorized Individual's Email Address (if any)

Authorized Individual's Mobile Telephone Number (if any)6.

Authorized Individual's Daytime Telephone Number5.

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.

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

prepared this application for me based only upon

information I provided or authorized.

The interpreter named in Part 8. read to me every

question and instruction on this application and my

answer to every question, in

1.b.

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.

Authorized Individual's Statement

a language in which I am fluent. I understand all of

this information as interpreted.

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.

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

Authorized Individual's Signature

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.

Form I-924 12/23/16 N Page 9 of 11

Part 8. Interpreter's Contact Information,

Certification, and Signature

Interpreter's Full Name

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

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

Interpreter's Business or Organization Name (if any)2.

Provide the following information about the interpreter.

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 Declaration and Certification, and

has verified the accuracy of every answer.

Interpreter's Signature7.a.

7.b.

Interpreter's Signature

Date of Signature (mm/dd/yyyy)

Interpreter's Mailing Address

3.c. City or Town

3.d. State 3.e. ZIP Code

3.f.

Postal Code3.g.

Province

3.h. Country

Street Number

and Name

3.a.

3.b.

Apt. Flr.Ste.

Interpreter's Daytime Telephone Number

Interpreter's Email Address (if any)

Interpreter's Contact Information

Interpreter's Mobile Telephone Number5.

Part 9. Contact Information, Declaration, and

Signature of the Person Preparing this

Application, if Other Than the Authorized

Individual

Preparer's Full Name

Provide the following information about the preparer.

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

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

Preparer's Business or Organization (if any)2.

NOTE: If applicable, provide the name of your accredited

organization recognized by the Board of Immigration Appeals

(BIA).

Preparer's Mailing Address

3.c. City or Town

3.d. State 3.e. ZIP Code

3.f.

Postal Code3.g.

Province

3.h. Country

Street Number

and Name

3.a.

3.b.

Apt. Flr.Ste.

Preparer's Contact Information

Preparer's Daytime Telephone Number

Preparer's Email Address (if any)

Preparer's Mobile Telephone Number (if any)5.

Form I-924 12/23/16 N Page 10 of 11

Part 9. Contact Information, Declaration, and

Signature of the Person Preparing This

Application, if Other Than the Authorized

Individual (continued)

Preparer's Statement

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.

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.

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.

7.a.

7.b.

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

Preparer's Signature8.a.

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

Form I-924 12/23/16 N Page 11 of 11

Part 10. Additional Information

3.d.

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.

3.a.

Page Number

3.b. Part Number 3.c. Item Number

6.a.

Page Number 6.b. Part Number 6.c. Item Number

6.d.

4.d.

4.a.

Page Number 4.b. Part Number 4.c. Item Number

5.d.

5.a.

Page Number 5.b. Part Number 5.c. Item Number

1. Name of the Regional Center Entity

Regional Center Identification Number2.