TD F 93.07 Report of Rejected Transactions

REPORT ON REJECTED TRANSACTION*

(Use of this form is optional, but the information requested is required by 31 C.F.R. § 501.604)

UNITED STATES DEPARTMENT OF THE TREASURY

OFFICE OF FOREIGN ASSETS CONTROL

OMB Form: TD-F 93.07

REPORTING INSTITUTION INFORMATION

INSTITUTION NAME
ADDRESS
CITY
STATE
POSTAL CODE
COUNTRY
CONTACT PERSON NAME
TITLE
TELEPHONE NUMBER
E-MAIL ADDRESS
DATE PREPARED

TRANSACTION INFORMATION

VALUE (USD)
VALUE DATE
DATE OF REJECTION
Type of Transaction (e.g., wire transfer, account, letter of credit, check, securities)
LEGAL AUTHORITY OR AUTHORITIES FOR REJECTING (e.g., 31 C.F.R Part 560)
SANCTIONS TARGET / NEXUS (e.g., sectoral sanctions target or commercial activity with Cuba, Iran, Syria, Crimea)
ORIGINATOR NAME & ADDRESS
ORIGINATING FINANCIAL INSTITUTION NAME & ADDRESS
Sender’s Correspondent (if applicable)
Receiver’s Correspondent (if applicable)
INTERMEDIARY FINANCIAL INSTITUTION NAME & ADDRESS
BENEFICIARY FINANCIAL INSTITUTION NAME & ADDRESS
BENEFICIARY NAME & ADDRESS
SENDER’S REFERENCE
BANK REFERENCE NUMBER
ORIGINATOR TO BENEFICIARY AND / OR BANK TO BANK INFORMATION

* For certain rejected transactions, some of the above fields may not be applicable. Complete all applicable fields and include all other relevant information (e.g., account number, check number, drawee bank) in the “Additional Relevant Information” field on page 2. To report blocked property, please use form “Report on Blocked Property – Tangible/Real/Other Non-financial Property”/OMB Form TD-F 93.08 or “Report on Blocked Property – Financial”/OMB Form TD-F 93.02, whichever is applicable.

PLEASE INCLUDE A COPY OF ANY PAYMENT OR TRANSFER INSTRUCTIONS OR OTHER RELEVANT DOCUMENTATION AS A SEPARATE ATTACHMENT

ADDITIONAL RELEVANT INFORMATION