OMB No. 1615-0061; Expires 03/31/2016

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

Department of Homeland Security
U.S. Citizenship and Immigration Services

Do Not Write in This Block - for USCIS Use Only (except G-28 block below)
Action Block

Fee Receipt

G-28 attached
Attorney's State License No.

Part 1. Information About Principal of the Regional Center
Name:

First

Last

Middle

C/O:
Street Address/P.O. Box:
City:

State:

Date of Birth
(mm/dd/yyyy):

Fax Number
(include area code):

Zip Code:
Telephone Number
(include area code):

Web site address:

Part 2. Application Type (Select one)
a. Initial Application for Designation as a Regional Center
b. Amendment to an approved Regional Center application. Note the previous application receipt number, if any (also attach the
Regional Center's previous approval notice):

Part 3. Information About the Regional Center
(Use a continuation sheet, if needed, to provide information for additional management companies/agencies, Regional Center
principals, agents, individuals or entities who are or will be involved in the management, oversight, and administration of the regional
center.)
A. Name of Regional Center:
Street Address/P.O. Box:
City:

State:

Web site address:

Fax Number (include area code): Telephone Number (include area code):

Zip Code:

Form I-924 03/18/15 Y Page 1

 Part 3. Information About the Regional Center (Continued)
B. Name of Managing Company/Agency:
Street Address/P.O. Box:
City:

State:

Web site address:

Fax Number (include area code): Telephone Number (include area code):

Zip Code:

C. Name of Other Agent:
Street Address/P.O. Box:
City:

State:

Web site address:

Fax Number (include area code): Telephone Number (include area code):

Zip Code:

D. Continuation, if needed, to provide information for additional management companies/agencies, regional center principals, agents,
individuals or entities who are or will be involved in the management, oversight, and administration of the regional center.)

Form I-924 03/18/15 Y Page 2

 Part 3. Information About the Regional Center (Continued)
Note: If extra space is needed to complete any item, attach a continuation sheet, indicate the item number, and provide the response.
1a. Describe the structure, ownership and control of the regional center entity.

b. Date the Regional Center was established(mm/dd/yyyy):
c. Organization Structure for the Regional Center:
1. Agency of a U.S. State or Territory (identify)
2. Corporation
3. Partnership (including Limited Partnership)
4. Limited Liability Company (LLC)
5. Other (Explain)
2. Has this regional center's designation ever been formally terminated by USCIS, or has the regional center ever filed a Form I-924
or regional center proposal or amendment that was denied?
No

Yes - Attach a copy of the adverse decision, with an explanation, the date of decision, and case number, if any.

3. Describe the geographic area of the regional center. Note: This area must be contiguous. Provide a map of the geographic area.

4. Describe the regional center's administration, oversight, and management functions that are or will be in place to monitor all EB-5
capital investment activities and the allocation of the resulting jobs created or maintained under the sponsorship of the regional
center.

Form I-924 03/18/15 Y Page 3

 Part 3. Information About the Regional Center (Continued)
5. Describe the past, current, and future promotional activities for the regional center. Include a description of the budget for this
activity, along with evidence of the funds committed to the regional center for promotional activities. Submit a plan of operation
for the regional center that addresses how EB-5 investors will be recruited, the methods by which the capital investment
opportunities will be offered to the investors, and how they will subscribe or commit to the investment interest.

6. Describe whether and how the regional center is engaged in supporting a due diligence screening of its alien investor's lawful
source of capital and the alien investor's ability to fully invest the requisite amount of capital. Also, describe the regional center's
prospective plans in this regard if they differ from past practice.

7. Identify each industry that has or will be the focus of EB-5 capital investments sponsored through the regional center.
Industry Category Title:

NAICS Code for the Industry Category:

Industry Category Title:

NAICS Code for the Industry Category:

Is the Form I-924 application supported by an economic analysis and
underlying business plan for the determination of prospective EB-5
job creation through EB-5 investments in this industry category?
No - Attach an explanation
Yes

Is the Form I-924 application supported by an economic analysis and
underlying business plan for the determination of prospective EB-5
job creation through EB-5 investments in this industry category?
No - Attach an explanation
Yes

Industry Category Title:

NAICS Code for the Industry Category:

Is the Form I-924 application supported by an economic analysis and
underlying business plan for the determination of prospective EB-5
job creation through EB-5 investments in this industry category?
No - Attach an explanation
Yes

Form I-924 03/18/15 Y Page 4

 Part 3. Information About the Regional Center (Continued)
8a. Describe and document the current and/or prospective structure of ownership and control of the commercial entities in which the
EB-5 alien investors have or will make their capital investments.

b. Date commercial enterprise established, if any (mm/dd/yyyy):
c. Organization Structure for commercial enterprise:
1. Corporation
2. Partnership (including Limited Partnership)
3. Limited Liability Company (LLC)
4. Other (Explain)
d. Has or will the Regional Center or any of its principals or agents have an equity stake in the commercial enterprise?
No

Yes - Attach an explanation and documentation that outlines when and under what circumstances these remittances
will be paid.

e. Has or will the Regional Center or any of its principals or agents receive fees, profits, surcharges, or other like remittances
through EB-5 capital investment activities from this commercial enterprise, beyond the minimum capital investment threshold
required of the EB-5 alien entrepreneurs?
No

Yes - Attach an explanation and documentation that outlines when and under what circumstances these remittances
will be paid.

Part 4. Applicant Signature Read the information on penalties in the instructions before completing this section. If
someone helped you prepare this petition, he or she must compete Part 5.

I certify, under penalty of perjury under the laws of the United States of America, that this form and the evidence submitted with it are
all true and correct. I authorize the release of any information from my records that U.S. Citizenship and Immigration Services needs
to determine eligibility for the benefit being sought. I also certify that I have authority to act on behalf of the Regional Center.
Signature of Applicant

Daytime Phone Number
(Area/Country Codes)

Printed Name of Applicant

E-Mail Address

Date (mm/dd/yyyy)

Relationship to the Regional Center Entity (Managing Member, President, CEO, etc.)

Form I-924 03/18/15 Y Page 5

 Part 5. Signature of Person Preparing This Form, If Other Than Above (Sign Below)
I declare that I prepared this application using information provided by someone with authority to act on behalf of the Regional
Center, and the answers and information provided by the Regional Center.
Attorney or Representative: In the event of a Request for Evidence (RFE), may the USCIS contact
you by Fax or E-mail?
Printed Name of Preparer

Signature of Preparer

No

Yes

Date (mm/dd/yyyy)

Firm Name and Address

Daytime Phone Number
(Area/Country Codes)

Fax Number (Area/
Country Codes)

E-Mail Address

Form I-924 03/18/15 Y Page 6