Form I-924a - Annual Certification Of Regional Center Page 2
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9Part 3. Reporting Period for Regional Center
9.b. Date of Birth (mm/dd/yyyy)
Activity
9.c. Country of Birth
Select only one box.
Reporting for the Federal fiscal year ending
1.
9.d. Percentage of Ownership in the Entity Listed in Part 4.,
September 30,
(yyyy).
Item Number 7.
%
Reporting for a series of Federal fiscal years
2.
9.e. Position Held (if any) in the Entity Listed in Part 4., Item
beginning October 1,
(yyyy) and ending
Number 7.
September 30,
(yyyy).
Other Names Used By the Principal Owner of the
Part 4. Information About the Organizational
Regional Center Entity (if applicable)
Structure, Ownership, and Control of Regional
10.a. Family Name
Center Entity
(Last Name)
10.b. Given Name
Information About the Principal Owners of the
(First Name)
Regional Center Entity
10.c. Middle Name
List and provide the required information for all persons or
legal entities or organizations that own or have a percentage of
11.
Trade Name (DBA if any) (for the entity listed in Part 4.,
ownership in the regional center entity.
Item Number 7.)
1.a. Family Name
(Last Name)
1.b. Given Name
Mailing Address for the Principal Owner of the
(First Name)
Regional Center Entity
1.c. Middle Name
12.a. In Care Of Name (if any)
2.
Date of Birth (mm/dd/yyyy)
12.b.
Street Number and
3.
Country of Birth
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.f. ZIP Code
%
12.g.
Province
6.
Position Held Within the Regional Center Entity (if any)
12.h.
Postal Code
7.
Entity Name (for an owner of the Regional Center Entity
12.i. Country
that is an entity or organization)
Contact Information for the Principal Owner of
8.
Federal Employer Identification Number (for an owner of
the Regional Center Entity
the Regional Center Entity that is an entity or organization)
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
Page 2 of 9
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