TD-F-90-22.60 Request for a Specific License to Visit a Family Member

OMB No.: 1505-0202

REQUEST FOR A SPECIFIC LICENSE TO VISIT AN IMMEDIATE FAMILY MEMBER

in Cuba who is a National of Cuba once in a three year period 31 C.F.R. § 515.561(a)

Complete each line with the requested information. Do NOT leave blank or write “N/A.”

APPLICANT INFORMATION

1. Last Name (Patronymic) ______________________ Last Name (Matronymic) ________________________

2. First Name ________________________________ Middle Name _________________________________

3. Last Name by Marriage _______________________ Date of Birth ________________________ (MM/DD/YYYY)

4. Street Address ______________________________________________Apt # _______________________

5. City ____________________State ________Zip Code ______________Phone # _____________________

6. U.S. Passport # ___________________________________ or ____ I Have no U.S. Passport.

7. U.S. Alien Registration # ____________________________ or ____ I Have no U.S. Alien Registration #.

8. Non-US Passport # ________________________________ Country of Issuance _____________

9. Last Family Visit under the _________________ (MM/DD/YYYY) or ____ Never used General License for former General License family visit

10. Last Family visit under ____________________ (MM/DD/YYYY) or ____ Never used Specific License for family

Specific License visit

11. Date of Emigration from Cuba ______________ (MM/DD/YYYY) or ____ Never emigrated from Cuba

THE PERSON YOU WISH TO VISIT IN CUBA

12. Last Name (Patronymic) ______________________ Last Name (Matronymic) ________________________

13. First Name _________________________________ Middle Name _________________________________

14. Relationship to Applicant ___________________Cuban Identification (Cedula ) #______________________

15. Address ________________________________________________City ____________________________

SERVICE PROVIDER INFORMATION

16. Check here ONLY if the Traveler has not used a Service Provider ____ Or complete the following:

Name of Service Provider______________________________________________________________________

Name of Service Provider Employee _____________________________________________________________

Street Address ______________________________________________________________Suite # __________

City _____________________State ________Zip Code _________________ Phone #_____________________

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WARNING: Transactions relating to travel, trade, and financial dealings with Cuba are restricted under the Cuban Assets Control Regulations,

31 C.F.R. Part 515, the Reporting and Procedures Regulations, 31 C.F.R. Part 501, and the Trading With the Enemy Act, 50 USC App. Section 5(b).

18 USC 1001 provides for up to 5 years imprisonment and a US$10,000 fine for any person who knowingly and willfully makes any materially false, fictitious, or fraudulent statement or representation on this form or in any other information submitted to OFAC. You are reminded that it is illegal to make use of charge cards during your stay in Cuba. Please be advised that each authorized traveler may carry no more than $300 of quarterly remittances to Cuba and may not return with any merchandise acquired in Cuba other than exempt informational materials.

SIGN BELOW: I have read the above statements, completed all numbered lines, and all the information provided above is true and accurate:

___________________________________ ___________________________________

SIGNATURE DATE (MM/DD/YYYY)

Office of Foreign Assets Control

This application should be mailed to the following address: U.S. Department of the Treasury

P.O. Box 229008

Miami FL 33222-9008

TD F 90-22.60