Form I-924 - Application For Regional Center Designation Under The Immigrant Investor Program Page 3

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Mailing Address for the Owners of the Regional
Part 4. Information About the Organizational
Center Entity
Structure, Ownership, and Control of the
Regional Center Entity (continued)
13.a. In Care Of Name (if any)
4.
Country of Birth
13.b.
Street Number and
Name or PO Box
5.
U.S. Social Security Number (if any)
Apt.
Ste.
Flr.
13.c.
►
13.d. City or Town
6.
Percentage of Ownership in the Regional Center Entity
%
13.e. State
13.f. ZIP Code
7.
Position Held Within the Regional Center Entity (if any)
13.g.
Province
13.h.
Postal Code
8.
Entity Name (for an owner of the Regional Center Entity
that is an entity or organization)
13.i. Country
9.
Federal Employer Identification Number (for an owner of
Contact Information for the Owners of the
the Regional Center Entity that is an entity or
Regional Center Entity
organization)
14.
Daytime Telephone Number
10.a. Persons Having Ownership, Control, or Beneficial
Interest in the Entity Listed in Part 4., Item Number 8.
15.
Fax Number
10.b. Date of Birth (mm/dd/yyyy)
Email Address (if any)
16.
10.c. Country of Birth
Website Address (if any)
17.
10.d. Percentage of Ownership in the Entity Listed in Part 4.,
Item Number 8.
%
Information About the Principals of the Regional
Center Entity - Non-Owners
10.e. Position Held (if any) in the Entity Listed in Part 4., Item
Number 8.
List all principals associated with the regional center, other than
those already identified in Part 4., Item Numbers 2.a. - 12.
For each person, include the principal non-owner's name, date
Other Names Used By the Owners of the Regional
of birth, country of birth, U.S. Social Security Number, the
Center Entity (if applicable)
position/title held within the regional center entity, and any
other names or aliases used. All principals are required to
Provide all other names the owner has ever used, including
provide a copy of a valid government-issued photo
aliases, maiden name, and nicknames.
identification document and should provide a U.S. Social
11.a. Family Name
Security Number. For each principal that is an entity or
(Last Name)
organization, provide the name of the entity, the Federal
11.b. Given Name
Employer Identification Number, any trade name (DBA), and
(First Name)
list the names of all persons having ownership, control, or a
beneficial interest in that entity or organization, their date of
11.c. Middle Name
birth, country of birth, the percentage of ownership, and the
Trade Name (DBA if any) (for the entity listed in Part 4.,
position held (if any) within the entity or organization. For each
12.
Item Number 8.)
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.
Form I-924 12/23/16 N
Page 3 of 11

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