Fillable I-924 Application for Regional Center Designation Under the ?Immigrant Investor Program

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

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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
2.
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.
2.
Indicate the type of projects submitted in support of the
application.
1.
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
8.
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)
9.
Federal Employer Identification Number (for an owner of
the Regional Center Entity that is an entity or
organization)
10.a.
Persons Having Ownership, Control, or Beneficial
Interest in the Entity Listed in Part 4., Item Number 8.
10.b. Date of Birth (mm/dd/yyyy)
10.c.
Country of Birth
10.d.
Percentage of Ownership in the Entity Listed in Part 4.,
Item Number 8.
10.e.
Position Held (if any) in the Entity Listed in Part 4., Item
Number 8.
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)
4.
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)
►
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
Other Governing Documents
Documentary Evidence of Regional Center
Ownership, Structure, Control and Administration,
Oversight, and Management Functions
Meeting Minutes or Written Consents
Annual Report
Equity Certificates
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 demonstrated that:
37.
The regional center focuses on a limited, contiguous
geographical area of the United States?
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.
41.
38.
The boundaries are reasonable based on evidence that the
proposed area is contributing significantly to the supply
chain and labor pool of the proposed new commercial
enterprises?
Yes No
39.
Regional Center Entity Federal Employer Identification
Number
NOTE: The geographic area covered by the regional
center must be a limited, contiguous, and clearly
identified area.
Promotional Activities
42.
Have you submitted documentation, such as a budget, that
details how the regional center has or will conduct
promotional activities?
Yes No
NOTE: You will need to provide a description and
submit documentation of the regional center's promotional
activities.
Form I-924 12/23/16 N Page 6 of 11
Part 4. Information About the Organizational
Structure, Ownership, and Control of the
Regional Center Entity (continued)
Plan of Operation
43.
Have you submitted a plan of operation that details how
EB-5 investors will be recruited, the methods by which
the capital investment opportunities will be offered, and
how potential investors will subscribe or commit to the
investment?
Yes No
NOTE: You must provide a description and submit
documentation of the regional center's operational plan
regarding investor recruitment, the types of investment
offerings, and the methods by which the investors will
subscribe or otherwise commit to the investments offered.
USCIS Actions on Prior Form I-924 Approval or Requests
for Designation As a Regional Center
44.
Has U.S. Citizenship and Immigration Services (USCIS)
ever terminated this regional center's designation; or has
the regional center entity, principal, managing company,
or agent involved with this application ever been
associated with a regional center whose designation was
terminated; or has the regional center entity, principal,
managing company, or agent involved with this
application ever filed Form I-924, Application for
Regional Center Designation Under the Immigrant
Investor Program, or Form I-924 amendment that was
denied?
Yes No
If you answered “Yes” to Item Number 44., provide an
explanation of the denial or termination and/or the association
between the regional center principal, managing company, or
owner and the denied or terminated regional center in Part 10.
Additional Information and the following information
associated with the denied or terminated regional center:
46.
Regional Center Identification Number
45.
Regional Center Name
2.
North American Industry Classification System (NAICS)
Code for Included Industry
3. Is Form I-924 supported by an economic analysis and
underlying business plan for determining prospective
EB-5 job creation through EB-5 investments in this
industry category?
Yes No
If you answered “No” to Item Number 3., explain in Part 10.
Additional Information.
4.
Nature of Industry (for example, furniture manufacturer)
5.
North American Industry Classification System (NAICS)
Code for Included Industry
6. Is this Form I-924 supported by an economic analysis and
underlying business plan for determining prospective
EB-5 job creation through EB-5 investments in this
industry category?
Yes No
If you answered “No” to Item Number 6., explain in Part 10.
Additional Information.
NOTE: For each additional industry, provide the information
requested above in Part 10. Additional Information.
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)
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.
2.
New Commercial Enterprise Federal Employer
Identification Number
1.
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)
%
3.
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)
6.
Country of Birth
9.
Entity Name (for an owner that is an entity or
organization)
8.
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.
7.
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.,
2.
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
6.
4.
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
6.
4.
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.
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I-924 Application for Regional Center Designation Under the Immigrant Investor Program

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Completed 17 November 2019

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