Form I-924a - Annual Certification Of Regional Center Page 3
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9Other Names Used By the Principal Non-Owner of
Part 4. Information About the Organizational
the Regional Center Entity (if applicable)
Structure, Ownership, and Control of Regional
Center Entity (continued)
25.a. Family Name
(Last Name)
Email Address (if any)
15.
25.b. Given Name
(First Name)
25.c. Middle Name
Website Address (if any)
16.
26.
Trade Name (DBA if any) (for the entity listed in Part 4.,
Item Number 26.
Information About the Principal Non-Owner of the
Regional Center Entity
Mailing Address for the Principal Non-Owner of
List and provide the required information for all principals
the Regional Center Entity
associated with the regional center, other than those already
identified in Part 4., Item Numbers 1.a. - 11.
27.a. In Care Of Name (if any)
17.a. Family Name
(Last Name)
17.b. Given Name
27.b.
Street Number and
(First Name)
Name or PO Box
17.c. Middle Name
27.c.
Apt.
Ste.
Flr.
18.
Date of Birth (mm/dd/yyyy)
27.d. City or Town
19.
Country of Birth
27.e. State
27.f. ZIP Code
27.g
Province
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
Contact Information for the Principal Non-Owner
that is an entity or organization)
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.
Fax Number
24.a. Persons Having Ownership, Control, or Beneficial
Interest in the Entity Listed in Part 4., Item Number 26.
Email Address (if any)
30.
24.b. Date of Birth (mm/dd/yyyy)
Website Address (if any)
31.
24.c. Country of Birth
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
Page 3 of 9
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