Step 1 of 9 11% FORM INSTRUCTIONS 1. Please complete this questionnaire completely. Enter “N/A” if any question is not applicable. Please do not leave blanks. a. Complete this questionnaire for the primary applicant and any spouse or dependents who you anticipate will be included in the final EB-5 petition to US Citizenship and Immigration Services. 2. Passport copies a. Attach a legible copy of the photo page of the primary applicant’s passport. b. If this questionnaire includes the primary applicant’s spouse and/or children, also attach a legible copy of the photo page of each dependent’s passport. c. If the signature page is separate from the photo page on any applicant’s passport, also attach a legible copy of the signature page. PRIMARY APPLICANT INFORMATIONName* First/Given Middle Name Last/Family OTHER NAMES USED OR ALIASES (including maiden name)*FULL NAME IN NATIVE ALPHABET*NATIONAL ID NUMBER (HOME COUNTRY)DATE OF BIRTH* MM slash DD slash YYYY GENDER* Male Female PASSPORT NUMBER*COUNTRY OF PASSPORT ISSUANCE*COUNTRY OF BIRTH*COUNTRY OF CURRENT LEGAL RESIDENCE*CURENT PERMANENT ADDRESS* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country CURRENT MARITAL STATUS* Single/Never Married Married Divorced Widowed NUMBER OF DEPENDENTS (excluding spouse)*CURRENT TELEPHONE NUMBER: ( ) - (Country Code) (Area Code) (Number)*CURRENT FAX NUMBER (Country Code) (Area Code) (Number)*ENGLISH PROFICIENCY* Need Translator Conversational Fluent OTHER LANGUAGES SPOKEN (if any)*EMAIL ADDRESS* FULL NAME OF CURRENT EMPLOYER (if any)* FOR PRIMARY APPLICANTS RESIDING IN THE UNITED STATESPRIMARY APPLICANTS Please fill out the information below if the primary applicant resides in the United States. If you do not reside in the United States, please check this box to indicate this section is not applicable: Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country DATE OF ARRIVAL MM slash DD slash YYYY CURRENT VISA TYPE (if any)I-94 NUMBERI-94 EXPIRATION DATE MM slash DD slash YYYY CURRENT NON-IMMIGRANT STATUS (if any) APPLICANT SPOUSE INFORMATION (IF APPLICABLE)Spouse Information please check this box to indicate this section is not applicable: Name Last/Family First/Given Middle Name OTHER NAMES USED OR ALIASES (including maiden name)FULL NAME IN NATIVE ALPHABETNATIONAL ID NUMBER (if any)DATE OF BIRTH MM slash DD slash YYYY GENDER Male Female PASSPORT NUMBERCOUNTRY OF PASSPORT ISSUANCECOUNTRY OF BIRTHCOUNTRY OF CURRENT LEGAL RESIDENCECURRENT EMAIL ADDRESS FULL NAME OF CURRENT EMPLOYER (if any) CHILDREN’S INFORMATION (IF APPLICABLE)CHILDREN’S INFORMATION please check this box to indicate this section is not applicable: Please provide the following information about each of your applicant children under the age of 21. Please list children in order from oldest to youngest.1. Name Last/Family First/Given Middle Name DATE OF BIRTH MM slash DD slash YYYY GENDER Male Female COUNTRY OF CITIZENSHIP2. Name Last/Family First/Given Middle Name DATE OF BIRTH MM slash DD slash YYYY GENDER Male Female COUNTRY OF CITIZENSHIP3. Name Last/Family First/Given Middle Name DATE OF BIRTH MM slash DD slash YYYY GENDER Male Female COUNTRY OF CITIZENSHIP4. Name Last/Family First/Given Middle Name DATE OF BIRTH MM slash DD slash YYYY GENDER Male Female COUNTRY OF CITIZENSHIP PRIMARY APPLICANT AND SPOUSE’S FINANCIAL RESOURCESPlease check the applicable boxes regarding your annual income.PRIMARY APPLICANT ONLYEXPECTED THIS YEAR Less than US $200,000 More than US $200,000 LAST YEAR Less than US $200,000 More than US $200,000 TWO YEARS AGO Less than US $200,000 More than US $200,000 PRIMARY APPLICANT PLUS SPOUSEEXPECTED THIS YEAR Less than US $300,000 More than US $300,000 LAST YEAR Less than US $300,000 More than US $300,000 TWO YEARS AGO Less than US $300,000 More than US $300,000 Please indicate the primary applicant’s net worth. For this purpose, “net worth” means total assets minus total liabilities, exclusive of the net value of your primary residence.PRIMARY APPLICANT’S NET WORTH (IN $US) Less than $1,000,000 $1,000,000 or more, but less than $2,000,000 $2,000,000 or more SOURCE OF FUNDS FOR EB-5 INVESTMENTSOURCE OF FUNDS Briefly describe each source of your EB-5 investment funds in the table below. If you are unsure of the source of your funds, please check this box: SOURCE OF FUNDS AMOUNT ($US) DESCRIPTION OF SOURCE OF FUNDS SavingsAMOUNT ($US)DESCRIPTION OF SOURCE OF FUNDSGiftAMOUNT ($US)DESCRIPTION OF SOURCE OF FUNDSLoanAMOUNT ($US)DESCRIPTION OF SOURCE OF FUNDSSale of Asset(s)AMOUNT ($US)DESCRIPTION OF SOURCE OF FUNDSInheritanceAMOUNT ($US)DESCRIPTION OF SOURCE OF FUNDSOtherAMOUNT ($US)DESCRIPTION OF SOURCE OF FUNDSTOTAL SOURCES OF FUNDSAMOUNT ($US)DESCRIPTION OF SOURCE OF FUNDSPlease check the relevant box if any of the funds for your EB-5 investment are coming from one or more of the following countries: Iran North Korea Sudan Syria FURTHER INFORMATION REGARDING GIFT FUNDS FOR EB-5 INVESTMENTFURTHER INFORMATION Complete this section for each gift included in your EB-5 investment source of funds. If you have already prepared a gift statement for your I-526 petition, please attach and return it with this completed questionnaire. If you are not utilizing gift funds, please check this box: SOURCE OF FUNDS GIFT #1 GIFT #2 (if any) GIFT #3 (if any) Gift Amount (US$)GIFT #1GIFT #2 (if any)GIFT #3 (if any)Full Name of Giving PersonGIFT #1GIFT #2 (if any)GIFT #3 (if any)Relationship to ApplicantGIFT #1GIFT #2 (if any)GIFT #3 (if any)Giver’s Current AddressGIFT #1GIFT #2 (if any)GIFT #3 (if any)Giver’s Country of CitizenshipGIFT #1GIFT #2 (if any)GIFT #3 (if any)Giver’s Passport Number and Country of IssuanceGIFT #1GIFT #2 (if any)GIFT #3 (if any)Giver’s Current EmployerGIFT #1GIFT #2 (if any)GIFT #3 (if any)Giver’s Current Job TitleGIFT #1GIFT #2 (if any)GIFT #3 (if any)Sources of Funds for Gift (check all that apply)Savings GIFT #1 GIFT #2 (if any) GIFT #3 (if any) Sale of real estate GIFT #1 GIFT #2 (if any) GIFT #3 (if any) Loan GIFT #1 GIFT #2 (if any) GIFT #3 (if any) Inheritance GIFT #1 GIFT #2 (if any) GIFT #3 (if any) Other (Please describe) If any gift funds are from non-individual sources (such as a trust or entity), please check this box: ADDITIONAL QUESTIONS - IMMIGRATION ATTORNEYPlease answer each question below:DO YOU HAVE AN IMMIGRATION ATTORNEY FOR THIS INVESTMENT? Yes No If Yes, please identify your counsel’s name, firm, telephone, and email address:ATTORNEY NAMEFIRMATTORNEY TELEPHONE: ( ) - (Country Code) (Area Code) (Number)ATTORNEY EMAIL ADDRESS If No, would you like a referral? Yes No ADDITIONAL QUESTIONS - GENERAL1. DO YOU EXPECT TO BE RESIDENT IN THE UNITED STATES PRIOR TO OR AT THE TIME OF MAKING AN EB-5 INVESTMENT? Yes No 2. IS ANY APPLICANT LISTED IN THIS QUESTIONNAIRE CURRENTLY A UNITED STATES PERMANENT RESIDENT (A “GREEN CARD” HOLDER)? Yes No If Yes, please identify the applicant(s) and current date on which the permanent residency or green card expires:Name Last/Family First/Given Middle Name DATE EXPIRED MM slash DD slash YYYY Name Last/Family First/Given Middle Name DATE EXPIRED MM slash DD slash YYYY 3. DOES ANY APPLICANT LISTED IN THIS QUESTIONNAIRE HOLD ANY U.S. VISA (EXAMPLES: STUDENT, TOURIST, BUSINESS)? Yes No If Yes, please identify:APPLICANT NAME(S): Last/Family First/Given Middle Name TYPE OF VISACURRENT DATE ON WHICH THE VISA EXPIRES MM slash DD slash YYYY LAST DATE OF ENTRY TO THE UNITED STATES: MM slash DD slash YYYY 4. HAS ANY APPLICANT LISTED IN THIS QUESTIONNAIRE EVER BEEN DENIED A UNITED STATES VISA OR GREEN CARD? Yes No If Yes, please identify the applicant(s) consulate location and reason for the denial:CONSULATE LOCATION:REASON FOR DENIAL:5. HAVE YOU OR ANY APPLICANT EVER STAYED IN THE U.S. BEYOND AUTHORIZATION? Yes No If Yes, please explain the circumstances:6. HAVE YOU OR ANY APPLICANT EVER HELD A J-1 VISA? Yes No If Yes, please provide the date of expiration: MM slash DD slash YYYY 7. DO YOU KNOW OF ANY MEDICAL CONDITION THAT MAY DISQUALIFY YOU, ANY APPLICANT, OR A DEPENDENT FROM ADMISSION TO THE U.S.? Yes No If Yes, please describe:8. HAVE YOU OR ANY APPLICANT EVER BEEN A MEMBER OF THE COMMUNIST PARTY? Yes No If Yes, please state the date joined and the date resigned, and whether any type of leadership position in the Communist Party was held at any time.DATE JOINED: MM slash DD slash YYYY LEADERSHIP POSITION:9. HAVE YOU, ANY APPLICANT, OR ANY DEPENDENT EVER BEEN CONVICTED OF ANY CRIME IN ANY JURISDICTION? Yes No If Yes, please provide the date, offense and resolution:10. HAS ANY APPLICANT EVER BEEN REFUSED ADMISSION TO THE UNITED STATES AT A PORT-OF-ENTRY? Yes No If Yes, please explain in detail:11. IS THERE ANY OTHER INFORMATION THAT COULD BE RELEVANT TO YOUR IMMIGRATION PROCESS THAT YOU HAVE NOT DISCLOSED? Yes No If Yes, please summarize: APPLICANT CERTIFICATION AND SIGNATUREI certify that all the information provided in this document is true and correct to the best of my knowledge.Passport Copy UploadAccepted file types: jpg, jpeg, png, gif, pdf, Max. file size: 50 MB.a. Attach a legible copy of the photo page of the primary applicant’s passport. b. If this questionnaire includes the primary applicant’s spouse and/or children, also attach a legible copy of the photo page of each dependent’s passport. Spouse/Child Passport CopyAccepted file types: jpg, jpeg, png, gif, pdf, Max. file size: 50 MB.Spouse/Child Passport CopyAccepted file types: jpg, jpeg, png, gif, pdf, Max. file size: 50 MB.Spouse/Child Passport CopyAccepted file types: jpg, jpeg, png, gif, pdf, Max. file size: 50 MB.Spouse/Child Passport CopyAccepted file types: jpg, jpeg, png, gif, pdf, Max. file size: 50 MB.APPLICANT NAMEDATE: MM slash DD slash YYYY Δ
