Form I-924 APPLICATION FOR REGIONAL CENTER DESIGNATION UNDER THE IM

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

START HERE - Type or print in black ink.

Part 1. Information About the Regional Center

1. Name of Regional Center Entity If filing an amendment to a previously approved Form I-924:

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

3. Regional Center Identification Number

Regional Center Mailing Address

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

4.b. Street Number and Name or PO Box

4.c. Apt. Ste. Flr.

4.d. City or Town

4.e. State

4.f. ZIP Code

Regional Center Contact Information

5. Daytime Telephone Number

6. Fax Number

7. Email Address (if any)

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

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)

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.

Part 3. Application Type

Select whether the application is an Initial Application or an Amendment.

1.a. Initial Application

Initial application for designation as a regional center.

Request to add a new commercial enterprise associated with the regional center. Provide the name of the added new commercial enterprise:

1.b. Amendment

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 change or modify the approved industries of focus 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.

2. Project Type

Indicate the type of projects submitted in support of the application.

Hypothetical

Actual

Actual with I-526 Exemplar

Part 4.  Information About the Organizational Structure, Ownership, and Control of the Regional Center Entity

1. Organizational Structure 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.

1.a. Agency of a U.S. state, territory, or local government

1.b. Corporation

1.c. Partnership (including limited partnerships)

1.d. Limited Liability Company (LLC)

1.e. Other (Describe below. If you need extra space to complete this section, use the space provided in

Part 10. Additional Information.)

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.

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)

4. Country of Birth

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

6. Percentage of Ownership in the Regional Center Entity %

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

8. Entity Name (for an owner of the Regional Center Entity that is an entity or organization)

9. Federal Employer Identification Number (for an owner of the Regional Center Entity that is an entity or organization)

10.a10. Persons Having Ownership, Control or Beneficial Interest in the Entity Listed in Part 4., Item Number 8.

10.b11. Date of Birth (mm/dd/yyyy)

10.c12. Country of Birth

10.d13. Percentage of Ownership in the Entity Listed in Part 4., Item Number 8. %

10.e14. Position Held (if any) in the Entity Listed in Part 4., Item Number 8.

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

Provide all other names you the owner hashave ever used, including aliases, maiden name, and nicknames. 

1115.a. Family Name (Last Name)

1115.b. Given Name (First Name)

1115.c. Middle Name

1216. Trade Name (DBA if any) (for the entity listed in Part 4., Item Number 8.)

Mailing Address for the Owners of the Regional Center Entity

1317.a. In Care Of Name (if any)

1317.b. Street Number and Name or PO Box

1317.c. Apt. Ste. Flr.

1317.d. City or Town

1317.e. State

1317.f. ZIP Code

1317.g. Province

1317.h. Postal Code

1317.i. Country

Contact Information for the Owners of the Regional Center Entity

1418. Daytime Telephone Number

1519. Fax Number

1620. Email Address (if any)

1721. Website Address (if any)

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. - 1512. 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.

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

1822.a. Family Name (Last Name)

1822.b. Given Name (First Name)

1822.c. Middle Name

1923. Date of Birth (mm/dd/yyyy)

2024. Country of Birth

2125. U.S. Social Security Number (if any)

2226. Position Held Within the Regional Center Entity

2327. Entity Name (for a principal of the Regional Center Entity that is an entity or organization)

2428. Federal Employer Identification Number (for a principal of the Regional Center Entity that is an entity or organization)

25.a29. Persons Having Ownership, Control or Beneficial Interest in the Entity Listed in Part 4., Item Number 2327.

25.b30. Date of Birth (mm/dd/yyyy)

25.c31. Country of Birth

25.d32. Percentage Ownership in the Entity Listed in Part 4., Item Number 2327. %

25.e33. Position Held (if any) in the Entity Listed in Part 4., Item Number 2327.

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

Provide all other names you the principal non-owner hashave ever used, including aliases, maiden name, and nicknames. 

2634.a. Family Name (Last Name)

26734.b. Given Name (First Name)

26734.c. Middle Name

27835. Trade Name (DBA if any) (for the entity listed in Part 4., Item Number 2327.)

Mailing Address For the Principal Non-Owners of the Regional Center Entity

28936.a. In Care Of Name (if any)

28936.b. Street Number and Name or PO Box

28936.c. Apt. Ste. Flr.

28936.d. City or Town

28936.e. State

28936.f. ZIP Code

28936.g. Province

28936.h. Postal Code

28936.i. Country

Contact Information For the Principal Non-Owners of the Regional Center Entity

293037. Daytime Telephone Number

303138. Fax Number

313239. Email Address (if any)

323340. Website Address (if any)

Information About the Regional Center

333441. Date the Regional Center Entity Was Established (mm/dd/yyyy)

343542. State or Territory Where the Regional Center Entity Was Formed

Geographic Area of the Regional Center

35643. 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.

36744. _{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.

Have you demonstrated that:

37845. The regional center focuses on a limited, contiguous geographical area of the United States? Yes No

38946. 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

NOTE: The geographic area covered by the regional center must be a limited, contiguous, and clearly identified area.

394047. Regional Center Entity Federal Employer Identification Number

Administration, Oversight and Management Functions

40148. 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.

Documentary Evidence of Regional Center Ownership, Structure, Control and Administration, Oversight and Management Functions

41249. 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

Meeting Minutes or Written Consents

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

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

42350. 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

43451. 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

44552. 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 44552., 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:

45653. Regional Center Name

46754. Regional Center Identification Number

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 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 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.

1. Name of the New Commercial Enterprise

2. New Commercial Enterprise Federal Employer Identification Number

Organizational Structure of the New Commercial Enterprises

3. 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.

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

7. Percentage of Ownership %

8. Position Held Within the New Commercial Enterprise (if any)

9. Entity Name (for an owner that is an entity or organization)

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.b12. Date of Birth (mm/dd/yyyy)

11.c13. Country of Birth

11.d14. Percentage of Ownership in the Entity Listed in Part 6., Item Number 9. %

11.e15. Position Held Within the Entity Listed in Item Number 8.a. of This Section (if any)

1216. Date New Commercial Enterprise Established (mm/dd/yyyy)

1317. State or Territory Where the New Commercial Enterprise Was Formed

Documentary Evidence of New Commercial Enterprise Ownership, Structure, Control and Administration, Oversight and Management Functions

1418. 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.

1519. 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 1519., provide an explanation in Part 10. Additional Information and submit documentation with this application that details such equity ownership.

1620. 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 1620., 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, Declaration, Certification, and Signature of the Applicant or Authorized Signatory Individual

NOTE: Read the Penalties section of the Form I-924 Instructions before completing this part.

Applicant's or Authorized SignatoryAuthorized Individual's Statement

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 as well as my answer to every question.

1.b. The interpreter named in Part 8. has read to me every question and instruction on this application, as well as and my answer to every question, in ______, a language in which I am fluent. I understood understand all of this information as interpreted.

2. At my request, the preparer named in Part 9., _______, prepared this application for me based only upon information I provided or authorized.

Authorized SignatoryAuthorized Individual's Contact Information

3.a. Authorized SignatoryAuthorized Individual's Family Name (Last Name)

3.b. Authorized SignatoryAuthorized Individual's Given Name (First Name)

4. Authorized SignatoryAuthorized Individual's Title

5. Authorized SignatoryAuthorized Individual's Daytime Telephone Number

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

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

Applicant's or Authorized SignatoryAuthorized Individual's Declaration and Certification

Copies of any documents submitted are exact photocopies of unaltered, original documents, and I understand that, as the applicant 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.

Applicant's or Authorized SignatoryAuthorized Individual's Signature

8.a. Applicant's Authorized Individual's Signature

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

NOTE TO ALL APPLICANTS AND AUTHORIZED SIGNATORIESINDIVIDUALS: 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.

Part 8.  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)

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

6. Interpreter's Email Address (if any)

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 this applicant or the authorized signatory individual in the identified language every question and instruction on this application and his or her answer to every question. The applicant or authorized signatory individual informed me that he or she understands every instruction, question, and answer on the application, including the Applicant's or Authorized Signatory's Individual's Declaration and Certification, and has verified the accuracy of every answer.

Interpreter's Signature

7.a. Interpreter's Signature

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

Part 9.  Contact Information, Declaration, and Signature of the Person Preparing This Form, if Other Than the Authorized IndividualApplicant

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 (if any)

NOTE: If applicable, provide the name of your accredited organization recognized by the Board of Immigration Appeals (BIA).

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

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 application on behalf of the applicant authorized individual of the regional center and with the authorized individual’s applicant's consent.

7.b. I am an attorney or accredited representative and my representation of the authorized individual applicant in this case

extends/does not extend beyond the preparation of this application.

NOTE: If you are an attorney or accredited representative whose representation extends beyond preparation of this application, you may be obliged to submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, with this application.

Preparer's Certification

By my signature, I certify, under penalty of perjury, that I prepared this application at the request of the applicant or authorized signatoryindividual of the regional center. The authorized individual applicant has reviewed this completed application, including the Applicant's or Authorized SignatoryIndividual'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

8.a. Preparer's Signature

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

Part 10. Additional Information

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.

1. Name of the Regional Center Entity

2. Regional Center Identification Number

3.a. Page Number

3.b. Part Number

3.c. Item Number

3.d. ___________

4.a. Page Number

4.b. Part Number

4.c. Item Number

4.d. ___________

5.a. Page Number

5.b. Part Number

5.c. Item Number

5.d. ___________

6.a. Page Number

6.b. Part Number

6.c. Item Number

6.d. ___________