Form TD F 90-22.50 TD F 90-22.50 Annual Report of Blocked Property

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Overview

Part A
Part B

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Sheet 1: Part A

			OMB No. 1505-0164
	ANNUAL REPORT OF BLOCKED PROPERTY UNITED STATES DEPARTMENT OF THE TREASURY OFFICE OF FOREIGN ASSETS CONTROL
	Part A - U.S. Person Holding Blocked Property
	(1) Enter the name and address of the person (e.g., specific financial institution or company) holding the blocked property.
		Name:	<Enter Detail Here>
		Address:	<Enter Detail Here>
		City:	<Enter Detail Here>
		State:	<Enter Detail Here>
		Postal code:	<Enter Detail Here>
		Country:	<Enter Detail Here>
	(2) Enter the contact details for the individual from whom additional information may be obtained.
		Name:	<Enter Detail Here>
		Title:	<Enter Detail Here>
		Telephone #:	<Enter Detail Here>
		Email:	<Enter Detail Here>
		Date prepared:	<Enter Detail Here>
	(3) Enter the total quantity of accounts or items reported in the Part B tab:		<Enter Detail Here>
	* Please note that the total quantity of accounts or items reported in section (3) must equal the total number of rows containing blocked assets in the Part B tab.
	Instructions for the Part B tab
	Identify each account or item of blocked property separately in the rows provided in the "Part B" tab. Be sure to indicate the total number of accounts or items reported on Part B in the appropriate space on Part A. Basic details regarding certain information requested in Part B are noted below, however, please refer to 31 C.F.R. 501.603(b)(2)(ii) and the Guidance on Filing the Annual Report of Blocked Property on OFAC's Reporting and License Application Forms webpage for further details on the information required to be reported.
	Date of Blocking	The date the property was blocked, if available.
	Value (USD)	Provide the actual or estimated value of the property in U.S. Dollars as of June 30. If a value date other than June 30 is reported, so indicate.
	Legal Authority or Authorities	Legal authority or authorities under which the property is blocked (e.g., 31 C.F.R. Part 515)
	Sanctions Target	The associated sanctions target whose property is blocked, or a reference to the relevant communication from OFAC instructing a party to block this property if that target is unknown.
	Owner of Property	The person who legally owns the account or other property. In the case of a blocked funds transfer, the party whose account is being debited to effect the transaction.
	Owner Type	Please indicate the owner type using the following categories: individual; U.S. bank; non-U.S. bank; U.S. non-bank entity; non-U.S. non-bank entity; or other.
	Description	A brief but comprehensive description of the property that is the subject of the blocking, including: • Asset Type (e.g., Bank account, check, wire transfer, stocks, real estate, tangible property • Account Type (e.g., checking, savings) • Account Number (if applicable for blocked financial assets)
	Location (city & country)	List the location or branch where the property is held, if different from the address shown in Part A.			.
	New Item? (Y/N)	"Please indicate "Y" if this is a new item that has not previously been reported. If this property was reported on the prior year's annual report, please indicate "N."
PAPERWORK REDUCTION ACT NOTICE Public reporting burden for this collection of information is estimated to average two hours per response. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information to the Office of Foreign Assets Control, U.S. Department of the Treasury, 1500 Pennsylvania Avenue, N.W., Freedman’s Bank Building, Washington, DC 20220.
TD-F 90-22.50

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Sheet 2: Part B

Date of Blocking

Value (USD)

Legal Authority or Authorities

Sanctions Target

Owner of Property

Owner Type

Asset Type

Account Type(s)

Account Number(s)

Additional Description of the Property (if needed)

Location: City

Location: Country

New Item? (Y/N)