Fillable I-924a Annual Certification of Regional Center

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I-924a Annual Certification of Regional Center

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Form I-924A Edition 11/21/19 Page 1 of 10
Annual Certification of Regional Center
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-924A
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
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. Ste. Flr.Apt.
Regional Center Contact Information
Fax Number7.
Daytime Telephone Number6.
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.
Ste. Flr.Apt.
Street Number and
Name or PO Box
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.
NOTE for Regional 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.
Select box if Form
G-28 is attached.
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)
8.
Email Address (if any)
9.
Website Address (if any)
Contact Information for Managing Company or
Agency
5.
Email Address (if any)
Fax Number 4.
Daytime Telephone Number 3.
6.
Website Address (if any)
Form I-924A Edition 11/21/19 Page 2 of 10
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 11. Additional Information.
Part 2. Information About the Managing
Company or Agency (if different from regional
center entity) (continued)
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
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
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.
September 30,
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)
►
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)
9.a.
Persons Having Ownership, Control or Beneficial Interest
in the Entity Listed in Part 4., Item Number 7.
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.
%
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.)
Provide all other names the principal 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 11. Additional Information.
Form I-924A Edition 11/21/19 Page 3 of 10
12.d. City or Town
12.e. State 12.f. ZIP Code
12.g.
Postal Code12.h.
Province
12.i. Country
12.b.
12.c.
Ste. Flr.Apt.
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.
Fax Number14.
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
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.
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)
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 22.
24.b. Date of Birth (mm/dd/yyyy)
24.c.
Country of Birth
24.e.
Position Held (if any) in the Entity Listed in Part 4., Item
Number 22.
24.d.
Percentage of Ownership in the Entity Listed in Part 4.,
Item Number 22.
%
►
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 22.
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 11. Additional Information.
Form I-924A Edition 11/21/19 Page 4 of 10
Part 4. Information About the Organizational
Structure, Ownership, and Control of Regional
Center Entity (continued)
27.d. City or Town
27.e. State 27.f. ZIP Code
27.g
Postal Code27.h.
Province
27.i. Country
27.b.
27.c.
Ste. Flr.Apt.
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
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.
2.
Aggregate Fees Or Other Remittances That Have Been
Paid To The Regional Center Or Any Of Its Principals,
Managing Companies Or Agencies, Or Agents
3.
Aggregate Non-EB-5 Capital Investment From All
Sponsored Projects
4.
Aggregate Number of Direct, Indirect, and/or Induced
Jobs Created For All Sponsored Projects
5.
Aggregate Number of Jobs Maintained Through
Investment in Troubled Businesses
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.
6.
Name of Industry
7.
North American Industry Classification System (NAICS)
Code for the Industry Category
8. Aggregate EB-5 Capital Investment
9. Aggregate Non-EB-5 Capital Investment
11.
Aggregate Number of Jobs Maintained Through
Investment in Troubled Businesses
10.
Aggregate Number of Direct, Indirect, and/or Induced
Jobs Created
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
13.
NAICS Code for the Industry Category
14. Aggregate EB-5 Capital Investment
15. Aggregate Non-EB-5 Capital Investment
12.
Name of Industry
Form I-924A Edition 11/21/19 Page 5 of 10
Part 5. Information About the Regional Center's
Operations (continued)
17.
Aggregate Number of Jobs Maintained Through
Investment in Troubled Businesses
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
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.
Ste. Flr.Apt.
Street Number and
Name or PO Box
NOTE for New 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.
Other Information
4. Name of Industry Receiving Investment Capital From the
New Commercial Enterprise
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?
Yes No
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.
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.
5.
16.
Aggregate Number of Direct, Indirect, and/or Induced
Jobs Created
Form I-924A Edition 11/21/19 Page 6 of 10
Part 6. Information About the New Commercial
Enterprise (continued)
ZIP Code
14.f.
State
City or Town
14.e.
14.d.
Mailing Address
14.a. In Care Of Name
14.b.
14.c.
Ste. Flr.Apt.
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 Numbers 14.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 Investor
(Form I-526)
Provide the total number of approved, denied, and revoked
Form I-526, Immigrant Petition by Alien Investor, 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-526 Petition Final Case Actions
2.
Approved
RevokedDenied
1. Name of the New Commercial Enterprise
Select only one result.
Petition By Investor to Remove Conditions
(Form I-829)
Provide the total number of approved and denied Form I-829,
Petition by Investor 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.
Approved Denied
Select only one result.
Part 8. Statement, Contact Information,
Certification, and Signature of the Authorized
Individual
NOTE: Read the Penalties section of the Form I-924A
Instructions before completing this section. You must file Form
I-924A while in the United States.
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 every question and instruction on this form
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.
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)
Form I-924A Edition 11/21/19 Page 7 of 10
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 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 certify, under penalty of perjury, that I provided or authorized
all of the information in my form, I understand all of the
information contained in, and submitted with, my form, and that
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.
If filing this form on behalf of an organization, I certify that I
am authorized to do so by the organization.
Authorized Individual's Signature
8.a.
8.b. Date of Signature (mm/dd/yyyy)
Authorized Individual's Signature
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
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.
Authorized Individual's Title4.
Part 8. Statement, Contact Information,
Certification, and Signature of the Authorized
Individual (continued)
NOTE TO ALL AUTHORIZED INDIVIDUALS: If you do
not completely fill out this form or fail to submit required
documents listed in the Instructions, USCIS may deny your
form.
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.
Ste. Flr.Apt.
Form I-924A Edition 11/21/19 Page 8 of 10
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 Certification, and has verified the
accuracy of every answer.
Part 9. Interpreter's Contact Information,
Certification, and Signature (continued)
Interpreter's Certification
Interpreter's Signature7.a.
7.b.
Interpreter's Signature
Date of Signature (mm/dd/yyyy)
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.
Preparer's Mailing Address
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 not an attorney or accredited representative but
have prepared this form on behalf of the authorized
individual and with the authorized individual's consent.
7.a.
Preparer's Statement
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 form.
7.b.
I am an attorney or accredited representative and my
representation of the authorized individual in this case
extends does not extend beyond the
preparation of this form.
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.
Ste. Flr.Apt.
Form I-924A Edition 11/21/19 Page 9 of 10
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 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 Edition 11/21/19 Page 10 of 10
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 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 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-924a Annual Certification of Regional Center

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Completed 2 July 2020

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