TD F 93.02 Report of Blocked Transactions

Reporting, Procedures and Penalties Regulations

TD-F 93.02 Blocking report_financial form (February 2019)

Reporting, Procedures and Penalties Regulations

OMB: 1505-0164

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REPORT ON BLOCKED PROPERTY – FINANCIAL*

(Use of this form is optional, but the information requested is required by 31 C.F.R. § 501.603)


Shape1 UNITED STATES DEPARTMENT OF THE TREASURY

OFFICE OF FOREIGN ASSETS CONTROL

OMB Form: TD-F 93.02

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 BLOCKING


Type of Transaction OR PROPERTY (e.g., wire transfer, account, letter of credit, check, securities)


LEGAL AUTHORITY OR AUTHORITIES FOR BLOCKING (e.g., 31 C.F.R Part 560)


SANCTIONS TARGET / NEXUS (e.g., name of Specially Designated National or blocked person)


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 blocked accounts, checks, letters of credit, securities, and other financial property, 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 other types of blocked property, please use the form “Report on Blocked Property – Tangible/Real/Other Non-financial Property”/OMB Form TD-F 93.08.

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

ADDITIONAL RELEVANT INFORMATION



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AuthorJames Kostiw
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