TD F 93.02 Report of Blocked Transactions

REPORT ON BLOCKED PROPERTY – FINANCIAL*

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

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