Form I 924A – Fill Out and Use This PDF

To be completed by an attorney or BIA-accredited representative (if any).

Select box if Form G-28 is attached.

Attorney State Bar Number

(if applicable)

Attorney or Accredited Representative USCIS Online Account Number (if any)

►START HERE - Type or print in black ink.

Part 1. Information About the Regional Center

1.Name of Regional Center Entity

2.Name of Regional Center (if different from regional center entity)

3.Regional Center Identification Number

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.

Part 2. Information About the Managing

Company or Agency (if different from regional center entity)

1.Name of Managing Company or Agency

Regional Center Mailing Address

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

5.b. Street Number and Name or PO Box

5.c. Apt. Ste. Flr.

5.d. City or Town

5.e. State		5.f. ZIP Code

Regional Center Contact Information

6.Daytime Telephone Number

7.Fax Number

8.Email Address (if any)

9.Website Address (if any)

Managing Company or Agency Mailing Address

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

2.b. Street Number and Name or PO Box

2.c. Apt. Ste. Flr.

2.d. City or Town

2.e. State		2.f. ZIP Code

Contact Information for Managing Company or Agency

3.Daytime Telephone Number

4.Fax Number

5.Email Address (if any)

6.Website Address (if any)

Part 2. Information About the Managing

Company or Agency (if different from regional center entity) (continued)

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.

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.

Part 3. Reporting Period for Regional Center Activity

Select only one box.

1. Reporting for the Federal fiscal year ending

	September 30,			(yyyy).
2.	Reporting for a series of Federal fiscal years
	beginning October 1,				(yyyy) and ending
	September 30,			(yyyy).

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.

Part 4. Information About the Organizational

Structure, Ownership, and Control of Regional

Center Entity

Information About the Principal Owners of the Regional Center Entity

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.

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

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

►

5.Percentage of Ownership of the Regional Center Entity

%

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

Other Names Used By the Principal Owner of the Regional Center Entity (if applicable)

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.

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.)

Part 4. Information About the Organizational

Structure, Ownership, and Control of Regional

Center Entity (continued)

Mailing Address for the Principal Owner of the Regional Center Entity

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

12.b. Street Number and Name or PO Box

12.c. Apt. Ste. Flr.

12.d. City or Town

12.e. State		12.f. ZIP Code

12.g. Province

12.h. Postal Code

12.i. Country

Contact Information for the Principal Owner of the Regional Center Entity

13.Daytime Telephone Number

14.Fax Number

15.Email Address (if any)

16.Website Address (if any)

Information About the Principal Non-Owner of the Regional Center Entity

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.

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

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

►

21.Position Held Within the Regional Center Entity

22.Entity Name (for a principal of the Regional Center Entity that is an entity or organization)

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.d. Percentage of Ownership in the Entity Listed in Part 4.,

Item Number 22.	%

24.e. Position Held (if any) 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)

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.

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.

Part 4. Information About the Organizational

Structure, Ownership, and Control of Regional

Center Entity (continued)

Mailing Address for the Principal Non-Owner of the Regional Center Entity

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

27.b. Street Number and Name or PO Box

27.c. Apt. Ste. Flr.

27.d. City or Town

27.e. State		27.f. ZIP Code

27.g Province

27.h. Postal Code

27.i. Country

Contact Information for the Principal Non-Owner of the Regional Center Entity

28.Daytime Telephone Number

29.Fax Number

30.Email Address (if any)

31.Website Address (if any)

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 Fees Or Other Remittances That Have Been Paid To The Regional Center Or Any Of Its Principals, Managing Companies Or Agencies, Or Agents

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

10.Aggregate Number of Direct, Indirect, and/or Induced Jobs Created

11.Aggregate Number of Jobs Maintained Through Investment in Troubled Businesses

12.Name of Industry

13.NAICS Code for the Industry Category

14.Aggregate EB-5 Capital Investment

15.Aggregate Non-EB-5 Capital Investment

Part 5. Information About the Regional Center's

Operations (continued)

16.Aggregate Number of Direct, Indirect, and/or Induced Jobs Created

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

New Commercial Enterprise Mailing Address

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

3.b. Street Number and Name or PO Box

3.c. Apt. Ste. Flr.

3.d. City or Town

3.e. State		3.f. ZIP Code

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

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

7.Aggregate Non-EB-5 Capital Investment

8.Aggregate Number of Direct, Indirect, and/or Induced Jobs Created

9.Aggregate Number of Jobs Maintained Through Investments in Troubled Businesses

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.

Information About the Job Creating Entity

11.Entity Name

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.

Part 6. Information About the New Commercial

Enterprise (continued)

Mailing Address

14.a. In Care Of Name

14.b. Street Number and Name or PO Box

14.c. Apt. Ste. Flr.

14.d. City or Town

14.e. State		14.f. ZIP Code

15.Aggregate EB-5 Capital Investment

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.Select only one result.

Approved Denied

16.Aggregate Non-EB-5 Capital Investment

17.Aggregate Number of Jobs Created

18.Aggregate Number of Jobs Maintained Through Investment in Troubled Businesses

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.

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

1.Name of the New Commercial Enterprise

2.Select only one result.

Approved Denied Revoked

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.

Authorized Individual's Statement

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.
1.b.	The interpreter named in Part 9. has read to me every
	question and instruction on this form and my answer to
	every question in
		,
	a language in which I am fluent, and I understood all
	of this information as interpreted.
2.	At my request, the preparer named in Part 10.,
		,
	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)

Part 8. Statement, Contact Information, Certification, and Signature of the Authorized

Individual (continued)

4.Authorized Individual's Title

5.Authorized Individual's Daytime Telephone Number

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

7.Authorized Individual's Email Address (if any)

Part 9. Interpreter's Contact Information, Certification, and Signature

Provide the following information about the interpreter.

Interpreter's Full Name

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

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

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

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 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.

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.

Authorized Individual's Signature

8.a. Authorized Individual's Signature

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

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.

Interpreter's Mailing Address

3.a. Street Number

and Name

3.b. Apt. Ste. Flr.

3.c. City or Town

3.d. State		3.e. ZIP Code

3.f. Province

3.g. Postal Code

3.h. Country

Interpreter's Contact Information

4.Interpreter's Daytime Telephone Number

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

6.Interpreter's Email Address (if any)

Part 9. Interpreter's Contact Information, Certification, and Signature (continued)

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 Certification, and has verified the accuracy of every answer.

Preparer's Mailing Address

3.a. Street Number

and Name

3.b. Apt. Ste. Flr.

3.c. City or Town

3.d. State		3.e. ZIP Code

3.f. Province

3.g. Postal Code

3.h. Country

Interpreter's Signature

7.a. Interpreter's Signature

7.b. 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

Provide the following information about the preparer.

Preparer's Full Name

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

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

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

Preparer's Contact Information

4.Preparer's Daytime Telephone Number

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

6.Preparer's Email Address (if any)

Preparer's Statement

7.a. 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.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.

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.

Part 11. Additional Information

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.

1.Name of Regional Center Entity

2.Regional Center Identification Number

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

5.d.