Annual Certification of Regional Center Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-924A OMB No. 1615-0061 Expires 12/31/2018 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. 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 regional center entity) 1. Name of Managing Company or Agency 2. Name of Regional Center (if different from regional center entity) 3. Regional Center Identification Number Managing Company or Agency Mailing Address 2.a. In Care Of Name (if any) 4. Regional Center Receipt Number 2.b. Street Number and Name or PO Box Regional Center Mailing Address 5.a. In Care Of Name (if any) 2.c. Apt. Ste. Flr. 2.d. City or Town 2.e. State 2.f. ZIP Code 5.b. Street Number and Name or PO Box 5.c. Apt. Ste. Flr. Contact Information for Managing Company or Agency 3. Daytime Telephone Number 5.d. City or Town 5.e. State 5.f. ZIP Code 4. Fax Number Regional Center Contact Information 6. Daytime Telephone Number 5. Email Address (if any) 7. Fax Number 6. Website Address (if any) 8. Email Address (if any) 9. 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 11. Additional Information. 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. Form I-924A 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 9 Part 3. Reporting Period for Regional Center Activity Select only one box. 1. Reporting for the Federal fiscal year ending September 30, 2. (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. Reporting for a series of Federal fiscal years beginning October 1, September 30, (yyyy) and ending (yyyy). 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. 3. Date of Birth (mm/dd/yyyy) Country of Birth 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.) 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. 4. U.S. Social Security Number (if any) 12.d. City or Town 5. Percentage of Ownership of the Regional Center Entity % 12.e. State 12.g. Province 12.h. Postal Code 12.f. ZIP Code 6. Position Held Within the Regional Center Entity (if any) 7. Entity Name (for an owner of the Regional Center Entity that is an entity or organization) 12.i. Country 8. Federal Employer Identification Number (for an owner of the Regional Center Entity that is an entity or organization) Contact Information for the Principal Owner of the Regional Center Entity 13. Daytime Telephone Number 9.a. Persons Having Ownership, Control or Beneficial Interest in the Entity Listed in Part 4., Item Number 7. 14. Fax Number Form I-924A 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 9 Part 4. Information About the Organizational Structure, Ownership, and Control of Regional Center Entity (continued) 15. Email Address (if any) 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 26. 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. 19. Date of Birth (mm/dd/yyyy) Country of Birth 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.g Province 27.f. ZIP Code 20. U.S. Social Security Number (if any) 27.h. Postal Code 21. Position Held Within the Regional Center Entity 27.i. Country 22. Entity Name (for a principal of the Regional Center Entity that is an entity or organization) Contact Information for the Principal Non-Owner of the Regional Center Entity 28. Daytime Telephone Number 23. Federal Employer Identification Number (for a principal of the Regional Center Entity that is an entity or organization) 29. 24.a. Persons Having Ownership, Control, or Beneficial Interest in the Entity Listed in Part 4., Item Number 26. Fax Number 30. Email Address (if any) 24.b. Date of Birth (mm/dd/yyyy) 24.c. Country of Birth 31. Website Address (if any) 24.d. Percentage of Ownership in the Entity Listed in Part 4., Item Number 26. % 24.e. Position Held (if any) in the Entity Listed in Part 4., Item Number 26. Form I-924A 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 9 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 aggre