Form I-924a - Annual Certification Of Regional Center Page 9

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5.a. Page Number
5.b. Part Number
5.c. Item Number
Part 11. Additional Information
If you need extra space to provide any additional information
within this form, use the space below. If you need more space
5.d.
than what is provided, you may make copies of this page to
complete and file with this form or attach a separate sheet of
paper. Type or print the regional center entity's name at the top
of each sheet; indicate the Page Number, Part Number, and
Item Number to which your answer refers; and sign and date
each sheet.
1.
Name of Regional Center Entity
2.
Regional Center Identification Number
3.a. Page Number
3.b. Part Number
3.c. Item Number
6.a. Page Number
6.b. Part Number
6.c. Item Number
3.d.
6.d.
4.a. Page Number
4.b. Part Number
4.c. Item Number
7.a. Page Number
7.b. Part Number
7.c. Item Number
4.d.
7.d.
Form I-924A 12/23/16 N
Page 9 of 9

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