EB-5 Investor Questionnaire PERSONAL INFORMATION Investor Name Investor Maiden Name (if applicable) Email Address Mobile Phone Gender Male Female Marital Status Single Married Divorced Widowed Date of Birth Place of Birth (City/Country) Country of Citizenship Passport Information Other Nationalities (if any) PRESENT ADDRESS ABROAD ADDRESS IN THE US (IF ANY) CURRENT US STATUS (IF APPLICABLE) Type of US Visa B Visitor F / M Student J1 / J2 Exchange Visitor Work Visa Other Visa Dates Last Entry Into US PRIOR VISA HISTORY Previous US Visas Have you ever been issued a US Visa? Have you ever been fingerprinted? Has your U.S. Visa ever been cancelled or revoked? Has your U.S. visa ever been lost or stolen? Have you ever been refused a U.S. Visa? SPOUSE INFORMATION (IF APPLICABLE) Male Female CHILDREN INFORMATION Same address as yours Add Another Child FINANCIAL CONDITION I have sufficient knowledge and experience in financial and business matters to evaluate this investment Annual income of US$200,000+ for past 3 years or combined marital income of US$300,000+ Net worth in excess of US$1,000,000 EMPLOYMENT & WORK HISTORY Are you retired? Are you a full-time student? INVESTMENT SOURCE OF FUNDS Intended Investment Funds Source Gift from: Loan from family Loan from Company/Bank Mortgage Loan Savings Other: Are you the sole and exclusive owner of the assets described above? TAX COMPLIANCE Do you have copies of 5 years of personal income tax returns? Is personal income tax paid in your country of tax residence? IMMIGRATION HISTORY If you answer YES to any question, please provide a written explanation Have all of the funds and assets used for this investment been legally obtained? Have you ever been involved in money laundering? Have you or your spouse ever filed for bankruptcy? Have you or your spouse ever been arrested, charged with a crime, or convicted of a crime? Do you have communicable diseases that endanger the public? Do you have a mental or physical disorder that poses a threat? Are you or have you ever been a drug abuser or addict? Have you or your spouse ever overstayed a visa to the US? Have you or your spouse ever been deported from the US? Have you or your spouse ever been refused admission to the US? Have you ever lied or committed fraud to obtain a visa or admission to the US? Have you ever claimed to be a US citizen? Have you ever voted or registered to vote in an election in the US? Do you seek to engage in espionage, sabotage, export control violations or other illegal activity in the US? Have you been involved with a paramilitary, vigilante, rebel, guerrilla or insurgent organization? Do you seek to engage in terrorist activities or are you a member of a terrorist organization? Have you ever engaged in terrorist activities anywhere in the world? Have you ever provided financial or other support to a terrorist organization? Have you ever been a member of the communist party? Have you ever incited or participated in genocide or been a member of the Nazi party? REQUIRED DOCUMENTS Please prepare the following documents to submit with your application: Valid government issued drivers license or National Identity card with photograph Valid passport (copy of picture page) Current US visa stamp or visitor visa, or Form I-797 Visa Approval Notice (if available) Form I-94 of each family member in the U.S. (if available) Signed personal income tax returns for the last five years Bank statements of 3-6 months for each account used Wire transfer confirmations Ownership documents proving ownership of shares Notarial deeds or contracts confirming ownership of real estate Written deed of gift (if applicable) Foreign business registration records (if applicable) Signed business income tax returns for the last five years (if applicable) CERTIFICATION I confirm that all of the information provided and documents submitted in response to this Investor Questionnaire are true, accurate and complete Submit Questionnaire Please enable JavaScript for this form to work.
