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OMB No. 1615-0061; Expires 09/30/2012 Form I-924A, Supplement to Form I-924 Department of Homeland Security U.S. Citizenship and Immigration Services Part 1. Information About Principal of the Regional Center Name: Last First Middle In Care Of: Street Address/P.O. Box: City: Date of Birth (mm/dd/yyyy): State: Zip Code: Fax Number (include area code): Telephone Number (include area code): Web site address: USCIS-assigned number for the Designated Regional Center (attach the Regional Center's most recently issued approval notice) Part 2. Application Type (Check one) a. Supplement for the Fiscal Year Ending September 30, (YYYY) b. Supplement for a Series of Fiscal Years Beginning on October 1, (YYYY) and Ending on September 30, (YYYY) 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: Web site Address: State: Fax Number (include area code): Zip Code: Telephone (include area code): B. Name of Managing Company/Agency: Street Address/P.O. Box: City: Web site Address: State: Fax Number (include area code): Zip Code: Telephone (include area code): C. Name of Other Agent: Street Address/P.O. Box: City: Web site Address: State: Fax Number (include area code): Zip Code: Telephone (include area code): Form I-924A (11/23/10) Part 3. Information About the Regional Center (Continued) Answer the following questions for the time period identified in Part 2 of this form. Note: If extra space is needed to complete any item, attach a continuation sheet, indicate the item number, and provide the response. 1. Identify the aggregate EB-5 capital investment and job creation has been the focus of EB-5 capital investments sponsored through the regional center. (Note: Separately identify jobs maintained through investments in “troubled businesses.”) Aggregate EB-5 Capital Investment Aggregate Jobs Maintained Aggregate Direct and Indirect Job Creation 2. Identify each industry that has been the focus of EB-5 capital investments sponsored through the Regional Center, and the resulting aggregate EB-5 capital investment and job creation. (Note: Separately identify jobs maintained through investments in “troubled businesses”.) a. Industry Category Title: Aggregate EB-5 Capital Investment: NAICS Code for the Industry Category Aggregate Direct and Indirect Job Creation: b. Industry Category Title: Aggregate EB-5 Capital Investment: NAICS Code for the Industry Category Aggregate Direct and Indirect Job Creation: c. Industry Category Title: Aggregate EB-5 Capital Investment: Aggregate Jobs Maintained: Aggregate Jobs Maintained: NAICS Code for the Industry Category Aggregate Direct and Indirect Job Creation: Aggregate Jobs Maintained: 3. Provide the following information for each job creating commercial enterprise located within the geographic scope of your regional center that has received EB-5 investor capital: a. Name of Commercial Enterprise: Industry Category Title: Address (Street Number and Name): City: State: Aggregate EB-5 Capital Investment: Aggregate Direct and Indirect Job Creation: Aggregate Jobs Maintained: Does this EB-5 commercial enterprise serve as a vehicle for investment into other business entities that have or will create or maintain jobs for EB-5 purposes? Zip Code: No Yes Form I-924A (11/23/10) Page 2 Part 3. Information About the Regional Center (Continued) If yes, then identify the name and address of each job creating business, as well as the amount of EB-5 capital investment and job creation/maintenance associated with each job creating business. Industry Category Title: (1) Business Name: Address (Street Number and Name): City: State: EB-5 Capital Investment: Direct and Indirect Job Creation: Jobs Maintained: (2) Business Name Zip Code: Industry Category Title: Address (Street Number and Name): City: State: EB-5 Capital Investment: Direct and Indirect Job Creation: Jobs Maintained: b. Name of Commercial Enterprise: Zip Code: Industry Category Title: Address (Street Number and Name): City: Aggregate EB-5 Capital Investment: Aggregate Direct and Indirect Job Creation: State: Zip Code: Aggregate Jobs Maintained: Does this EB-5 commercial enterprise serve as a vehicle for investment into other business entities that have or will create or maintain jobs for EB-5 purposes? No Yes If yes, then identify the name and address of each job creating business, as well as the amount of EB-5 capital investment and job creation/maintenance associated with each job creating business. Industry Category Title: (1) Business Name: Address (Street Number and Name): City: EB-5 Capital Investment Direct and Indirect Job Creation State: Zip Code Jobs Maintained Form I-924A (11/23/10) Page 3 Part 3. Information About the Regional Center (Continued) (2) Business Name: Industry Category Title: Address (Street Number and Name): City: EB-5 Capital Investment: Direct and Indirect Job Creation: c. Name of Commercial Enterprise: State: Zip Code: Jobs Maintained: Industry Category Title: Address (Street Number and Name): City: Aggregate EB-5 Capital Investment: Aggregate Direct and Indirect Job Creation: State: Zip Code: Aggregate Jobs Maintained: Does this EB-5 commercial enterprise serve as a vehicle for investment into other business entities that have or will create or maintain jobs for EB-5 purposes? No Yes If yes, then identify the name and address of each job creating business, as well as the amount of EB-5 capital investment and job creation/maintenance associated with each job creating business. Industry Category Title: (1) Business Name: Address (Street Number and Name): City: State: EB-5 Capital Investment: Direct and Indirect Job Creation: Jobs Maintained: (2) Business Name: Zip Code: Industry Category Title: Address (Street Number and Name): City: State: EB-5 Capital Investment: Direct and Indirect Job Creation: Jobs Maintained: Zip Code: Form I-924A (11/23/10) Page 4 Part 3. Information About the Regional Center (Continued) d. Name of Commercial Enterprise: Industry Category Title: Address (Street Number and Name): City: State: Aggregate EB-5 Capital Investment: Aggregate Direct and Indirect Job Creation: Aggregate Jobs Maintained: Zip Code: Does this EB-5 commercial enterprise serve as a vehicle for investment into other business entities that have or will create or maintain jobs for EB-5 purposes? No Yes If yes, then identify the name and address of each job creating business, as well as the amount of EB-5 capital investment and job creation/maintenance associated with each job creating business. Industry Category Title: (1) Business Name: Address (Street Number and Name): City: State: EB-5 Capital Investment: Direct and Indirect Job Creation: Jobs Maintained: (2) Business Name: Zip Code: Industry Category Title: Address (Street Number and Name): City: EB-5 Capital Investment: Direct and Indirect Job Creation: e. Name of Commercial Enterprise: State: Zip Code: Jobs Maintained: Industry Category Title: Address Street Number and Name: City: State: Aggregate EB-5 Capital Investment: Aggregate Direct and Indirect Job Creation: Aggregate Jobs Maintained: Does this EB-5 commercial enterprise serve as a vehicle for investment into other business entities that have or will create or maintain jobs for EB-5 purposes? Zip Code: No Yes Form I-924A (11/23/10) Page 5 Part 3. Information About the Regional Center (Continued) If yes, then identify the name and address of each job creating business, as well as the amount of EB-5 capital investment and job creation/maintenance associated with each job creating business. Industry Category Title: (1) Business Name: Address (Street Number and Name): City: EB-5 Capital Investment: Direct and Indirect Job Creation: State: Zip Code: Jobs Maintained: Industry Category Title: (2) Business Name: Address (Street Number and Name): City: State: EB-5 Capital Investment: Direct and Indirect Job Creation: Zip Code: Jobs Maintained: 4. Provide the total number of approved, denied and revoked Form I-526 petitions filed by EB-5 investors making capital investments sponsored by the regional center. (Note: If an adverse action was ultimately reversed and the petition was approved, then note the case as approved.) Form I-526 Petition Final Case Actions Approved Denied Revoked 5. Provide the total number of approved, denied and revoked Form I-829 petitions filed by EB-5 investors making capital investments sponsored by the regional center. (Note: If an adverse action was ultimately reversed and the petition was approved, then note the case as approved.) Form I-829 Petition Final Case Actions Approved Denied Revoked NOTE: USCIS may require case-specific data relating to individual EB-5 petitions and the job creation determination and further information regarding the allocation methodologies utilized by a regional center in certain instances in order to verify the aggregate data provided above. Form I-924A (11/23/10) Page 6 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 supplemental 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 Printed Name of Applicant Daytime Phone Number (Area/Country Codes) E-Mail Address Date (mm/dd/yyyy) Relationship to the Regional Center Entity (Managing Member, President, CEO, etc.) Part 5. Signature of Person Preparing This Form, If Other Than Above (Sign Below) I declare that I prepared this form using information provided by someone with authority to act on behalf of the Regional Center, and the answers and information are those 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? Signature of Preparer Printed Name 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-924A (11/23/10) Page 7