Application for Regional Center Designation Under the Immigrant Investor Program Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-924 OMB No. 1615-0061 Expires 12/31/2018 To be completed by an attorney or BIA-accredited representative (if any). Select box if G-28 is attached to represent the regional center 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 Part 2. Information About the Managing Company or Agency (if different from the regional center entity) 1. Name of the Managing Company or Agency If filing an amendment to a previously approved Form I-924: 2. Name of Regional Center (if different from regional center entity) Managing Company or Agency Mailing Address 2.a. In Care Of Name (if any) 3. Regional Center Identification Number 2.b. Street Number and Name or PO Box 2.c. Apt. Ste. Flr. Regional Center Mailing Address 4.a. In Care Of Name (if any) 2.d. City or Town 4.b. Street Number and Name or PO Box 4.c. Apt. Ste. Flr. 2.e. State 2.f. ZIP Code Contact Information for Managing Company or Agency 3. Daytime Telephone Number 4.d. City or Town 4.e. State 4.f. ZIP Code 4. Fax Number Regional Center Contact Information 5. Daytime Telephone Number 5. 6. Fax Number 6. 7. Email Address (if any) Email Address (if any) Website Address (if any) 8. 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. Form I-924 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 11 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: 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 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.) 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: 1.b. 1.c. 1.d. 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 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 Information About the Owners of the Regional Center Entity 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name 3. Date of Birth (mm/dd/yyyy) Form I-924 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 11 Part 4. Information About the Organizational Structure, Ownership, and Control of the Regional Center Entity (continued) 4. Country of Birth Mailing Address for the Owners of the Regional Center Entity 13.a. In Care Of Name (if any) 13.b. Street Number and Name or PO Box 5. U.S. Social Security Number (if any) 13.c. 6. Percentage of Ownership in the Regional Center Entity % 7. Position Held Within the Regional Center Entity (if any) 13.g. Province 8. Entity Name (for an owner of the Regional Center Entity that is an entity or organization) 13.h. Postal Code 13.i. Country Apt. Ste. Flr. 13.d. City or Town 13.e. State 13.f. ZIP Code 9. Federal Employer Identification Number (for an owner of the Regional Center Entity that is an entity or organization) Contact Information for the Owners of the Regional Center Entity 14. Daytime Telephone Number 10.a. Persons Having Ownership, Control, or Beneficial Interest in the Entity Listed in Part 4., Item Number 8. 15.