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 Edition 11/21/19 Page 1 of 11
Select box if Form
G-28 is attached.
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 11/30/2021
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. Ste. Flr.Apt.
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
Managing Company or Agency Mailing Address
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)
ZIP Code
2.f.
State
City or Town
2.e.
2.d.
2.a. In Care Of Name (if any)
2.b.
2.c.
Ste. Flr.Apt.
Street Number and
Name or PO Box
Do Not Write in This
Block - for USCIS
Use Only (except
G-28 block below)
Action Block
Fee Receipt
G-28 attached
Attorney's State License Number
Form I-924 Edition 11/21/19 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 Alien
Investor, for that new commercial enterprise, before
individual investors file their petitions. Please
provide the name of the added new commercial
enterprise:
Amendment to notify U.S. Citizenship and
Immigration Services (USCIS) of changes in the
name, organizational structure or administration,
capital investment instruments, or offering
memoranda (including changes in the economic
analysis and underlying business plan used to estimate
job creation) for a previously added new commercial
enterprise associated with the regional center.
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.
Select 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 Edition 11/21/19 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.
13.e.
13.g.
13.h.
13.i.
13.b.
13.c.
Mailing Address for the Owners of the Regional
Center Entity
13.a.
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)
%
%
5. U.S. Social Security Number (if any)
4.
Country of Birth
►
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. If you need extra space
to complete this section, use the space provided in Part 10.
Additional Information.
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
City or Town
State 13.f. ZIP Code
Postal Code
Province
Country
Ste. Flr.Apt.
In Care Of Name (if any)
Street Number and
Name or PO Box
Form I-924 Edition 11/21/19 Page 4 of 11
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.
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)
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.
%
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.)
Provide all other names the principal non-owner has ever used,
including aliases, maiden name, and nicknames. If you need
extra space to complete this section, use the space provided in
Part 10. Additional Information.
28.d.
28.e.
28.g.
28.h.
28.i.
28.b.
28.c.
Mailing Address For the Principal Non-Owners of
the Regional Center Entity
28.a.
City or Town
State 28.f. ZIP Code
Postal Code
Province
Country
Ste. Flr.Apt.
In Care Of Name (if any)
Street Number and
Name or PO Box
Form I-924 Edition 11/21/19 Page 5 of 11
Part 4. Information About the Organizational
Structure, Ownership, and Control of the
Regional Center Entity (continued)
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)
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.
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.
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
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.
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
41.
Annual Report
Equity Certificates
Organizational Information Identifying the Regional
Center as a Unit of an Agency or Municipality of a
U.S. State or Territory
Have you demonstrated that:
37.
The regional center focuses on a limited, contiguous
geographical area of the United States?
Yes No
Form I-924 Edition 11/21/19 Page 6 of 11
Part 4. Information About the Organizational
Structure, Ownership, and Control of the
Regional Center Entity (continued)
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.
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.
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, how
potential investors will subscribe or commit to the
investment, how the regional center will conduct investor
due diligence, and explains any and all fees or other
remittances that will be paid to the regional center or any
of its principals, managing companies or agencies, or
agents?
Yes No
NOTE: You must provide a description and submit
documentation of the regional center's operational plan
regarding investor recruitment, the types of investment
offerings, and the methods by which the investors will
subscribe or otherwise commit to the investments offered.
USCIS Actions on Prior Form I-924 Approval or Requests
for Designation As a Regional Center
44. Has USCIS ever terminated this regional center's
designation; or has the regional center entity, principal,
managing company, or agent involved with this
application ever been associated with a regional center
whose designation was terminated; or has the regional
center entity, principal, managing company, or agent
involved with this application ever filed Form I-924,
Application for Regional Center Designation Under the
Immigrant Investor Program, or Form I-924 amendment
that was denied?
Yes No
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)
2.
North American Industry Classification System (NAICS)
Code for Included Industry
3. Is this Form I-924 supported by an economic analysis and
underlying business plan for determining prospective
EB-5 job creation through EB-5 investments in this
industry category?
Yes No
If you answered “No” to Item Number 3., explain in Part 10.
Additional Information.
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.
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
Form I-924 Edition 11/21/19 Page 7 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
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
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.)
3.
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.
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
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 %
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 Part 6., Item
Number 9. (if any)
%
Form I-924 Edition 11/21/19 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)
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.
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.
Part 7. Statement, Contact Information,
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. has 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 and my answer to every question.
Authorized Individual's Statement
a language in which I am fluent, and I understood all
of this information as interpreted.
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.
Form I-924 Edition 11/21/19 Page 9 of 11
Authorized Individual's 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 Signature8.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 deny your application.
Part 7. Statement, Contact Information,
Certification, and Signature of the Authorized
Individual (continued)
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)
Provide the following information about the interpreter.
Interpreter's Mailing Address
3.c.
3.d.
3.f.
3.g.
3.h.
3.a.
3.b.
Interpreter's Daytime Telephone Number
6.
4.
Interpreter's Email Address (if any)
Interpreter's Contact Information
Interpreter's Mobile Telephone Number5.
Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and ,
which is the same language specified in Part 7., Item Number
1.b., and I have read to the authorized individual in the
identified language every question and instruction on this
application and his or her answer to every question. The
authorized individual informed me that he or she understands
every instruction, question, and answer on the application,
including the Authorized Individual's Certification, and has
verified the accuracy of every answer.
Interpreter's Signature
7.a.
7.b.
Interpreter's Signature
Date of Signature (mm/dd/yyyy)
City or Town
State 3.e. ZIP Code
Postal Code
Province
Country
Street Number
and Name
Ste. Flr.Apt.
Interpreter's Business or Organization Name (if any)2.
Form I-924 Edition 11/21/19 Page 10 of 11
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.
Preparer's Mailing Address
3.c.
3.d.
3.f.
3.g.
3.h.
3.a.
3.b.
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.
Preparer's Statement
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 need 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 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)
I am an attorney or accredited representative and my
representation of the authorized individual in this case
extends
preparation of this application.
does not extend beyond the
City or Town
State 3.e. ZIP Code
Postal Code
Province
Country
Street Number
and Name
Ste. Flr.Apt.
Form I-924 Edition 11/21/19 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.
7.a. Page Number
7.b. Part Number 7.c. Item Number
7.d.
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I-924 Application for Regional Center Designation Under the Immigrant Investor Program

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Completed 2 July 2020

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