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Fillable Printable Form I-924A

Fillable Printable Form I-924A

Form I-924A

Form I-924A

Form I-924A 12/23/16 NPage 1 of 9
Annual Certification of Regional Center
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-924A
OMB No. 1615-0061
Expires 12/31/2018
START HERE - Type or print in black ink.
Part 1. Information About the Regional Center
2.
Name of Regional Center (if different from regional
center entity)
1.Name of Regional Center Entity
4.Regional Center Receipt Number
3.Regional Center Identification Number
ZIP Code
5.f.
State
City or Town
5.e.
5.d.
Regional Center Mailing Address
5.a.In Care Of Name (if any)
Street Number and
Name or PO Box
5.b.
5.c.Apt.Flr.Ste.
Regional Center Contact Information
8.
Email Address (if any)
Fax Number7.
Daytime Telephone Number6.
9.
Website Address (if any)
Part 2. Information About the Managing
Company or Agency (if different from regional
center entity)
1.Name of 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 forMultiple Managing Companies or Agencies: If
more than one managing company or agency is associated with
the regional center, provide the above information for all other
managing companies or agencies in the space provided in Part
11. Additional Information.
Street Number and
Name or PO Box
NOTE forRegional Center Mailing Address: If the regional
center mailing address is different from the physical address,
please provide the physical address of the regional center in the
space provided in Part 11. Additional Information.
If you need extra space to complete any section of this request or if you would like to provide additional information about your
circumstances, use the space provided in Part 11. Additional Information. Complete and submit as many copies of Part 11., as
necessary, with your request.
Form I-924A 12/23/16 NPage 2 of 9
Part 3. Reporting Period for Regional Center
Activity
1.
Reporting for the Federal fiscal year ending
2.
Select only one box.
(yyyy).
Reporting for a series of Federal fiscal years
(yyyy) and ending beginning October 1,
(yyyy).
Part 4. Information About the Organizational
Structure, Ownership, and Control of Regional
Center Entity
9.b.Date of Birth (mm/dd/yyyy)
9.c.
Country of Birth
9.d.
Percentage of Ownership in the Entity Listed in Part 4.,
Item Number 7.
9.e.
Position Held (if any) in the Entity Listed in Part 4., Item
Number 7.
%
September 30,
Information About the Principal Owners of the
Regional Center Entity
1.a.Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c.Middle Name
2.Date of Birth (mm/dd/yyyy)
3.
Country of Birth
5.Percentage of Ownership of the Regional Center Entity
6.Position Held Within the Regional Center Entity (if any)
%
4.U.S. Social Security Number (if any)
Other Names Used By the Principal Owner of the
Regional Center Entity (if applicable)
10.a.Family Name
(Last Name)
10.b.
Given Name
(First Name)
10.c.Middle Name
11.Trade Name (DBA if any) (for the entity listed in Part 4.,
Item Number 7.)
7.
Entity Name (for an owner of the Regional Center Entity
that is an entity or organization)
8.
Federal Employer Identification Number (for an owner of
the Regional Center Entity that is an entity or organization)
12.d.City or Town
12.e.State12.f. ZIP Code
12.g.
Postal Code12.h.
Province
12.i.Country
12.b.
12.c.
Apt.Flr.Ste.
Mailing Address for the Principal Owner of the
Regional Center Entity
12.a.In Care Of Name (if any)
Street Number and
Name or PO Box
Contact Information for the Principal Owner of
the Regional Center Entity
Daytime Telephone Number13.
List and provide the required information for all persons or
legal entities or organizations that own or have a percentage of
ownership in the regional center entity.
9.a.
Persons Having Ownership, Control or Beneficial Interest
in the Entity Listed in Part 4., Item Number 7.
Fax Number14.
September 30,
Form I-924A 12/23/16 NPage 3 of 9
Part 4. Information About the Organizational
Structure, Ownership, and Control of Regional
Center Entity (continued)
15.
Email Address (if any)
16.
Website Address (if any)
Information About the Principal Non-Owner of the
Regional Center Entity
17.a.Family Name
(Last Name)
17.b. Given Name
(First Name)
17.c.Middle Name
18.Date of Birth (mm/dd/yyyy)
19.
Country of Birth
22.
Entity Name (for a principal of the Regional Center Entity
that is an entity or organization)
21.Position Held Within the Regional Center Entity
20.U.S. Social Security Number (if any)
Other Names Used By the Principal Non-Owner of
the Regional Center Entity (if applicable)
25.a.Family Name
(Last Name)
25.b. Given Name
(First Name)
25.c.Middle Name
26.Trade Name (DBA if any) (for the entity listed in Part 4.,
Item Number 26.
27.d.City or Town
27.e.State27.f. ZIP Code
27.g
Postal Code27.h.
Province
27.i.Country
27.b.
27.c.
Apt.Flr.Ste.
Mailing Address for the Principal Non-Owner of
the Regional Center Entity
27.a.In Care Of Name (if any)
Street Number and
Name or PO Box
23.
Federal Employer Identification Number (for a principal of
the Regional Center Entity that is an entity or organization)
24.a.
Persons Having Ownership, Control, or Beneficial
Interest in the Entity Listed in Part 4., Item Number 26.
24.b.Date of Birth (mm/dd/yyyy)
24.c.
Country of Birth
Contact Information for the Principal Non-Owner
of the Regional Center Entity
Daytime Telephone Number28.
30.
Email Address (if any)
31.
Website Address (if any)
Fax Number29.
List and provide the required information for all principals
associated with the regional center, other than those already
identified in Part 4., Item Numbers 1.a. - 11.
24.e.
Position Held (if any) in the Entity Listed in Part 4., Item
Number 26.
24.d.
Percentage of Ownership in the Entity Listed in Part 4.,
Item Number 26.
%
Form I-924A 12/23/16 NPage 4 of 9
Part 5. Information About the Regional Center's
Operations
Aggregate Capital Investment and Job Creation
Provide the aggregate capital investment and job creation that
has been the focus of the EB-5 capital investments sponsored
through the regional center.
NOTE: Please indicate the number of jobs maintained through
investments in “troubled businesses” separate from aggregate
job creation as indicated below.
1.
Aggregate EB-5 Capital Investment From All Sponsored
Projects
2.
Aggregate Non-EB-5 Capital Investment From All
Sponsored Projects
3.
Aggregate Number of Direct, Indirect, and/or Induced
Jobs Created For All Sponsored Projects
4.
Aggregate Number of Jobs Maintained Through
Investment in Troubled Businesses
12.
NAICS Code for the Industry Category
13.Aggregate EB-5 Capital Investment
16.
Aggregate Number of Jobs Maintained Through
Investment in Troubled Businesses
14.Aggregate Non-EB-5 Capital Investment
15.
Aggregate Number of Direct, Indirect, and/or Induced
Jobs Created
Industries and Resulting Aggregate Capital
Investment and Job Creation
Identify each industry and the resulting aggregate capital
investment and job creation from the EB-5 capital investments
sponsored through the regional center.
5.
Name of Industry
6.
North American Industry Classification System (NAICS)
Code for the Industry Category
7.Aggregate EB-5 Capital Investment
8.Aggregate Non-EB-5 Capital Investment
Part 6. Information About the New Commercial
Enterprise
Provide the following information for each new commercial
enterprise associated with the regional center that has received
EB-5 investor capital. If the regional center oversees more than
one new commercial enterprise, provide the information below
for each additional new commercial enterprise in Part 11.
Additional Information.
NOTE: Please indicate the number of jobs maintained through
investments in “troubled businesses” separate from aggregate
job creation as indicated below.
1.Name of the New Commercial Enterprise
2.
New Commercial Enterprise Federal Employer
Identification Number
10.
Aggregate Number of Jobs Maintained Through
Investment in Troubled Businesses
9.
Aggregate Number of Direct, Indirect, and/or Induced
Jobs Created
ZIP Code
3.f.
State
City or Town
3.e.
3.d.
New Commercial Enterprise Mailing Address
3.a.In Care Of Name (if any)
3.b.
3.c.Apt.
Flr.Ste.
Street Number and
Name or PO Box
11.
Name of Industry
Form I-924A 12/23/16 NPage 5 of 9
NOTE forNew Commercial Enterprise Mailing Address: If
the new commercial enterprise mailing address is different from
the physical address, please provide the physical address of the
new commercial enterprise in the space provided in Part 11.
Additional Information.
Part 6. Information About the New Commercial
Enterprise (continued)
Other Information
4.Name of Industry Receiving Investment Capital From the
New Commercial Enterprise
5.
NAICS Code for the Industry Category
If more than one industry is receiving investment capital from
the new commercial enterprise, provide the name and NAICS
code for each additional industry category in the space provided
in Part 11. Additional Information.
6.Aggregate EB-5 Capital Investment
9.
Aggregate Number of Jobs Maintained Through
Investments in Troubled Businesses
7.Aggregate Non-EB-5 Capital Investment
8.
Aggregate Number of Direct, Indirect, and/or Induced
Jobs Created
10.Does the new commercial enterprise serve as a vehicle for
investment into other job creating entities that have or
will create or maintain jobs for EB-5 purposes?
YesNo
If you answered“Yes”to Item Number 10., identify the name
and address of each job creating entity, its industry, as well as
the aggregate capital investment and job creation associated
with each job creating entity.
NOTE: Please indicate the number of jobs maintained through
investments in “troubled businesses” separate from aggregate
job creation as indicated below.
11.Entity Name
Information About the Job Creating Entity
12.
Job Creating Entity Federal Employer Identification
Number
13.Name of Industry
If more than one industry is associated with the job creating
entity, provide the name for each additional industry category in
the space provided in Part 11. Additional Information.
ZIP Code
14.f.
State
City or Town
14.e.
14.d.
Mailing Address
14.a.In Care Of Name
14.b.
14.c.Apt.
Flr.Ste.
Street Number and
Name or PO Box
15.Aggregate EB-5 Capital Investment
16.Aggregate Non-EB-5 Capital Investment
17.
Aggregate Number of Jobs Created
NOTE: If the address in Item Numbers14.a. - 14.f. of this
section refers to the mailing address of the job creating entity,
please provide the physical address of the new commercial
enterprise in the space provided in Part 11. Additional
Information.
18.
Aggregate Number of Jobs Maintained Through
Investment in Troubled Businesses
Part 7. Petitions Filed by EB-5 Investors
Immigrant Petition by Alien Entrepreneur
(Form I-526)
Provide the total number of approved, denied, and revoked Form
I-526, Immigrant Petition by Alien Entrepreneur,petitions filed
by EB-5 investors making capital investments in each new
commercial enterprise associated with the regional center.
NOTE: If an adverse action was ultimately reversed and the
petition was approved, then list the case as approved.
Form I-924A 12/23/16 NPage 6 of 9
Form I-526 Petition Final Case Actions
2.
Approved
RevokedDenied
1.Name of the New Commercial Enterprise
Select only one result.
Petition By Entrepreneur to Remove Conditions
(Form I-829)
Provide the total number of approved and denied Form I-829,
Petition by Entrepreneur to Remove Conditions, petitions filed
by EB-5 investors making capital investments in each new
commercial enterprise associated with the regional center.
Form I-829 Petition Final Case Actions
3.Name of New Commercial Enterprise
4.
ApprovedDenied
Select only one result.
Part 8. Statement, Contact Information,
Declaration, Certification, and Signature of the
Authorized Individual
NOTE: Read the Penalties section of the Form I-924A
Instructions before completing this part.
At my request, the preparer named in Part 10.,
2.
,
The interpreter named in Part 9. has read to me every
question and instruction on this form and my answer to
every question in
1.b.
,
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 each and every question and instruction on
this form and my answer to each question.
Applicant's or Authorized Individual's Statement
a language in which I am fluent. I understood all of
this information as interpreted.
prepared this form 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)
Authorized Individual's Title4.
7.
Authorized Individual's Email Address (if any)
Authorized Individual's Mobile Telephone Number (if any)6.
Authorized Individual's Daytime Telephone Number5.
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's, I may be required to submit original
documents to USCIS at a later date.
I certify, under penalty of perjury, that I have reviewed this
form, I understand all of the information contained in, and
submitted with, this form, and all of this information is
complete, true, and correct.
I authorize the release of any information from my records, or
from the petitioning organization's records, to USCIS or other
entities and persons where necessary to determine eligibility for
the immigration benefit sought or where authorized by law. I
recognize the authority of USCIS to conduct audits of this form
using publicly available open source information. I also
recognize that any supporting evidence submitted in support of
this form may be verified by USCIS through any means
determined appropriate by USCIS, including but not limited to,
on-site compliance reviews.
I am filing this form on behalf of the regional center entity, and
I certify that I am authorized to do so by the regional center
entity.
Form I-924A 12/23/16 NPage 7 of 9
Authorized Individual's Signature
8.a.
8.b.Date of Signature (mm/dd/yyyy)
Authorized Individual's Signature
NOTE TO ALL REGIONAL CENTERS AND
AUTHORIZED INDIVIDUALS: If you do not completely
fill out this form or fail to submit required documents listed in
the Instructions, USCIS may reject your form. USCIS will
issue a notice of intent to terminate the participation of the
regional center in the Immigrant Investor Program if a regional
center fails to submit the required information or upon a
determination that the regional center no longer serves the
purpose of promoting economic growth.
Part 9. 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 Mailing Address
3.c.City or Town
3.d.State3.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
6.
4.
Interpreter's Email Address (if any)
Interpreter's Contact Information
Interpreter's Mobile Telephone Number (if any)5.
Interpreter's Signature7.a.
7.b.
Interpreter's Signature
Date of Signature (mm/dd/yyyy)
Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and , which
is the same language provided in Part 8., Item Number 1.b.,
and I have read to the authorized individual in the identified
language every question and instruction on this form and his or
her answer to every question. The authorized individual
informed me that he or she understands every instruction,
question, and answer on the form, including the Authorized
Individual's Declaration and Certification, and has verified
the accuracy of every answer.
Part 10. Contact Information, Declaration, and
Signature of the Person Preparing this Form, 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 Name (if any)2.
Part 8. Statement, Contact Information,
Declaration, Certification, and Signature of the
Authorized Individual (continued)
Form I-924A 12/23/16 NPage 8 of 9
Preparer's Mailing Address
3.c.City or Town
3.d.State3.e. ZIP Code
Street Number
and Name
3.a.
3.b.
Apt.Flr.Ste.
Province3.f.
Postal Code3.g.
3.h.Country
Preparer's Contact Information
Preparer's Daytime Telephone Number
6.
4.
Preparer's Email Address (if any)
Preparer's Mobile Telephone Number (if any)5.
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 form.
I am not an attorney or accredited representative but
have prepared this form on behalf of the authorized
individual and with the authorized individual's consent.
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 form.
7.a.
7.b.
Preparer's Statement
Preparer's Signature
Preparer's Signature8.a.
8.b.Date of Signature (mm/dd/yyyy)
Preparer's Certification
By my signature, I certify, under penalty of perjury, that I
prepared this form at the request of the authorized individual.
The authorized individual has reviewed this completed form,
including the Authorized Individual's Declaration and
Certification, and informed me that all of this information in
the form and in the supporting documents is complete, true, and
correct.
Part 10. Contact Information, Declaration, and
Signature of the Person Preparing this Form, if
Other Than the Authorized Individual(continued)
Form I-924A 12/23/16 NPage 9 of 9
Part 11. Additional Information
3.d.
If you need extra space to provide any additional information
within this form, use the space below. If you need more space
than what is provided, you may make copies of this page to
complete and file with this form or attach a separate sheet of
paper. Type or print the regional center entity's name at the top
of each sheet; indicate the Page Number, Part Number,and
Item Number to which your answer refers; and sign and date
each sheet.
3.a.
Page Number
3.b.Part Number3.c.Item Number
6.a.
Page Number6.b.Part Number6.c.Item Number
6.d.
4.d.
4.a.
Page Number4.b.Part Number4.c.Item Number
5.d.
5.a.
Page Number5.b.Part Number5.c.Item Number
1.Name of Regional Center Entity
Regional Center Identification Number2.
7.a.
Page Number
7.b.Part Number7.c.Item Number
7.d.
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