TD F 93.02 Report of Blocked Transactions

OMB No. 1505-0164

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
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” (Form TD-F 93.08).

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

TD-F 93.02

ADDITIONAL RELEVANT INFORMATION

Public reporting burden for this collection of information is estimated to average 30 minutes 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.