TD F 98-22.61 OFAC License Application Cover Letter

0MB No. 1505-0164

D Supplemental Information

Date:

OFAC License Application Cover Sheet
Form TD-F 98-22.61

To learn more about applying for a license, please visit OFAC's website at: https://ofac.treasury.gov. OFAC
encourages electronic submission of license applications at: https://ofac.treasury.gov/ofac-license-application-page
If unable to submit an application electronically, you can mail this form to OFAC at: Office of Foreign Assets Control,
US Department of the Treasury, 1500 Pennsylvania Ave NW, Washington, DC 20220, Attn: Licensing Division.
Please do not use this Cover Sheet if your application should be submitted on a different OFAC-issued form,
such as an Application for the Release of Blocked Funds (Form TD-F 90-22.54) or in another OFAC specified format.

Applicant
Program(s):

Previous licensing
Case ID, if applicable:

Category:
Describe the subject matter of this correspondence:

Actual Party (Recipient of the License)
Name:
First:
Institution Name:
line 1 :
Address:
line 2:
line 3:
City:
Zip Code:
Email Address:
Office:
Phone Number:
Mobile:
Fax:

Applicant Reference
#: Subcategory:

Middle:

Last:

State:
Country:

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Correspondent (If different from actual party)
First:
Name:
Institution Name:
line 1:
Address:
line 2:
line 3:
City:
Zip Code:
Email Address:
Office:
Phone Number:
Mobile:
Fax:
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State:
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PAPERWORK REDUCTION ACT NOTICE
Public reporting burden for this collection of information is estimated to average 15 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, US Department of the Treasury, 1500 Pennsylvania Ave NW, Washington, DC 20220.

TD-F 98-22.61