Form CISADA Model Form CISADA Model Form Certification

Note: This appendix will not appear in the Code of Federal Regulations; however, FinCEN will use its website to make this model certification available to the public.

Appendix A

Certification for Purposes of Section 104(e) of the Comprehensive Iran Sanctions, Accountability, and Divestment Act of 2010 and 31 CFR § 1060.300

OMB Control Number 1506-0066

The information contained in this Certification is sought for purposes of Section 104(e) of the Comprehensive Iran Sanctions, Accountability, and Divestment Act of 2010 (“CISADA”) (Public Law 111-195). This Certification will be used to provide the Department of the Treasury, through the Financial Crimes Enforcement Network (“FinCEN”), with information regarding the nature of foreign bank activities that may be relevant to CISADA.

This Certification may be completed by a foreign bank that maintains a correspondent account with a U.S. bank (see definitions below). An entity that is not a foreign bank is not required to complete this Certification.

A Foreign Bank is a bank organized under foreign law, or an agency, branch, or office located outside the United States of a bank (see definition at 31 CFR § 1010.100(u)). A Bank includes each agent, agency, branch, or office within the United States of persons doing business in one or more of the following capacities: commercial banks or trust companies, private banks, savings and loan associations, national banks, thrift institutions, credit unions, other organizations chartered under banking laws and supervised by banking supervisors of any State, and banks organized under foreign law (see definition at 31 CFR § 1010.100(d)).

A Correspondent Account for a foreign bank is an account established for a foreign bank to receive deposits from, or to make payments or other disbursements on behalf of, the foreign bank, or to handle other financial transactions related to such foreign bank (see definition at 31 CFR § 1010.605(c)(1)(ii)).

An Iranian-Linked Financial Institution Designated Under IEEPA is a financial institution designated by the United States Government pursuant to the International Emergency Economic Powers Act (“IEEPA”) (or listed in an annex to an Executive order issued pursuant to such Act) in connection with Iran's proliferation of weapons of mass destruction or delivery systems for weapons of mass destruction, or in connection with Iran's support for international terrorism. Iranian-Linked Financial Institutions Designated Under IEEPA are identified by “[IFSR]” tags located at the end of their entries on the Specially Designated Nationals and Blocked Persons List (“SDN List”) (e.g., [NPWMD][IFSR] or [SDGT][IFSR]). The Office of Foreign Assets Control’s (“OFAC”) electronic SDN List can be found at the following URL: http://www.treasury.gov/resource-center/sanctions/SDN-List/Pages/default.aspx. The following financial institutions meet the criteria of Iranian-Linked Financial Institutions Designated Under IEEPA ([IFSR] tags): http://www.treasury.gov/resource-center/sanctions/Programs/Documents/irgc_ifsr.pdf. These listings are part of the SDN List, administered by OFAC. Please note that OFAC’s SDN List is dynamic and should be reviewed regularly for the most current information regarding Iranian-Linked Financial Institutions Designated Under IEEPA.

An IRGC-Linked Person Designated Under IEEPA is Iran’s Islamic Revolutionary Guard Corps or any of its agents or affiliates designated by the United States Government pursuant to IEEPA (or listed in an annex to an Executive order issued pursuant to such Act). IRGC-Linked Persons Designated Under IEEPA are identified by “[IRGC]” tags located at the end of their entries on the SDN List (e.g., [NPWMD][IRGC] or [SDGT][IRGC]). OFAC’s electronic SDN List can be found at the following URL: http://www.treasury.gov/resource-center/sanctions/SDN-List/Pages/default.aspx. The following persons meet the criteria of IRGC-Linked Persons Designated Under IEEPA ([IRGC] tags): http://www.treasury.gov/resource-center/sanctions/Programs/Documents/irgc_ifsr.pdf. These listings are part of the SDN List, administered by OFAC. Please note that OFAC’s SDN List is dynamic and should be reviewed regularly for the most current information regarding IRGC-Linked Persons Designated Under IEEPA.

1. The undersigned financial institution, __________________________ (“Foreign Bank”) hereby certifies as follows: (Note: Foreign Bank should check one box in each of sections B, C, and D in order to complete the Certification).

2. Correspondent Account maintained for an Iranian-Linked Financial Institution Designated Under IEEPA: Check one box to certify.

□ Foreign Bank hereby certifies that it does not maintain a correspondent account(s) for an Iranian-Linked Financial Institution Designated Under IEEPA.

□ Foreign Bank hereby certifies that it does maintain a correspondent account(s) for an Iranian-Linked Financial Institution Designated Under IEEPA. (If this box has been selected please fill out the below information for each correspondent account maintained for an Iranian-Linked Financial Institution Designated Under IEEPA).

	Iranian-Linked Financial Institution Designated Under IEEPA	Full Name(s) on Correspondent Account	Correspondent Account Number(s)	Applicable Information regarding whether the Correspondent Account has been Blocked or Otherwise Restricted *	Other Applicable Identifying Information for the Correspondent Account	Approximate Value in U.S. Dollars (“USD”) of Transactions Processed through the Correspondent Account Within Preceding 90 Calendar Days
1
2
3
4
5

(Add more rows as needed)

* Please include other applicable information such as whether the account(s) has been restricted or blocked in accordance with laws or policies, whether the account(s) is dormant, or whether the account(s) activity has been subject to specific exceptions to otherwise applicable restrictions, such as an account(s) licensed by a competent authority in the foreign bank’s home jurisdiction.

3. Processed one or more transfers of funds for or on behalf of, directly or indirectly, an Iranian-Linked Financial Institution Designated Under IEEPA, other than through a correspondent account: Check one box to certify.

□ Foreign Bank hereby certifies that to its knowledge it has not processed one or more transfers of funds within the preceding 90 calendar days for or on behalf of, directly or indirectly, an Iranian-Linked Financial Institution Designated Under IEEPA, other than through a correspondent account detailed above.

□ Foreign Bank hereby certifies that it has processed one or more transfers of funds within the preceding 90 calendar days for or on behalf of, directly or indirectly, an Iranian-Linked Financial Institution Designated Under IEEPA, other than through a correspondent account detailed above. (If this box has been selected please fill out the below information for each Iranian-Linked Financial Institution Designated Under IEEPA).

	Iranian-Linked Financial Institution Designated Under IEEPA	Identify System or Means by Which Transfer(s) of Funds Was Processed	Full Name on Account(s) (if applicable)	Account Number(s) (if applicable)	Other Applicable Identifying Information for the Transfer(s) of Funds *	Approximate Value in USD of Transfer(s) of Funds Processed (other than through a Correspondent Account) Within Preceding 90 Calendar Days
1
2
3
4
5

(Add more rows as needed)

* Please include other applicable information such as whether the transfer(s) of funds has been subject to specific exceptions to otherwise applicable restrictions, such as a transfer(s) of funds licensed by a competent authority in the foreign bank’s home jurisdiction.

4. Processed one or more transfers of funds for or on behalf of, directly or indirectly, an IRGC-Linked Person Designated Under IEEPA: Check one box to certify.

□ Foreign Bank hereby certifies that to its knowledge it has not processed one or more transfers of funds within the preceding 90 calendar days for or on behalf of, directly or indirectly, an IRGC-Linked Person Designated Under IEEPA.

□ Foreign Bank hereby certifies that it has processed one or more transfers of funds within the preceding 90 calendar days for or on behalf of, directly or indirectly, an IRGC-Linked Person Designated Under IEEPA. (If this box has been selected please fill out the below information for each IRGC-Linked Person Designated Under IEEPA).

	IRGC- Linked Person Designated Under IEEPA	Identify System or Means by Which Transfer(s) of Funds Was Processed	Full Name on Account(s) (if applicable)	Account Number(s) (if applicable)	Other Applicable Identifying Information for the Transfer(s) of Funds *	Approximate Value in USD of Transfer(s) of Funds Processed Within Preceding 90 Calendar Days
1
2
3
4
5

(Add more rows as needed)

* Please include other applicable information such as whether the transfer(s) of funds has been subject to specific exceptions to otherwise applicable restrictions, such as a transfer(s) of funds licensed by a competent authority in the foreign bank’s home jurisdiction.

5. General

Foreign Bank hereby agrees to notify in writing the Bank if Foreign Bank establishes a new correspondent account for an Iranian-Linked Financial Institution Designated Under IEEPA at any time within 365 calendar days from the date of this response. Foreign Bank agrees to provide such notification within 30 calendar days of the establishment of the new correspondent account.

Foreign Bank understands that the Bank will provide a copy of this Certification to FinCEN, a bureau of the U.S. Department of the Treasury. Foreign Bank further understands that the statements contained in this Certification may be transmitted to one or more departments or agencies of the United States of America for the purpose of fulfilling such departments’ and agencies’ governmental functions.

I, _________________________(name of signatory), certify that I have read and understand this Certification, that the statements made in this Certification are complete and correct, and that I am authorized to execute this Certification on behalf of Foreign Bank.

____________________________________

[Name of Foreign Bank]

_____________________________________

[Signature]

_____________________________________

[Printed Name]

_____________________________________

[Title]

Executed on this _______day of __________, 20___.

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To be completed by the Bank:

I, _________________________(name of signatory), have received and reviewed this Certification. To the best of its knowledge, the Bank has no information that is inconsistent with the Certification made by Foreign Bank. I am authorized to submit this document on behalf of the Bank.

____________________________________

[Name of Bank]

_____________________________________

[Signature]

_____________________________________

[Printed Name]

_____________________________________

[Title]

Submitted on this _______day of __________, 20___.

Paperwork Reduction Act Notice

Public reporting burden for this collection of information is estimated to average three hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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. The valid OMB control number for this information collection is 1506-0066. You may submit comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, by calling the FinCEN Resource Center at 800-767-2825 or by email at [email protected]. Alternatively, you may mail us comments at Policy Division, Financial Crimes Enforcement Network, P.O. Box 39, Vienna, VA 22183. Please include 1506–0066 in the body of the text.