Report of Russian Sovereign Assets Form

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REPO Report Form

OMB No. 1505-0164
REPORT OF RUSSIAN SOVEREIGN ASSETS UNDER THE REBUILDING ECONOMIC PROSPERITY AND OPPORTUNITY
FOR UKRAINIANS ACT
UNITED STATES DEPARTMENT OF THE TREASURY
OFFICE OF FOREIGN ASSETS CONTROL
Part A - U.S. Person Holding Russian Sovereign Assets
(1) Enter the name and address of the person (e.g., specific financial institution) holding the Russian sovereign asset.
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 Russian
soverign assets in the Part B tab.

Instructions for the Part B tab
Identify each account or item of Russian sovereign assets 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. Pursuant to section 2 of the Rebuilding Economic Prosperity and Opportunity for Ukrainians
Act, the term “Russian sovereign asset” means any of the following: (A) Funds and other property of (i) the Central Bank of the
Russian Federation, (ii) the Russian National Wealth Fund, or (iii) the Ministry of Finance of the Russian Federation; or (B) any other
funds or other property that are owned by the Government of the Russian Federation, including by any subdivision, agency, or
instrumentality of that government. Financial institutions may rely on reports regarding Russian sovereign assets located at the
financial institution that are filed pursuant to Directive 4 under E.O. 14024 or in reports of blocked property filed pursuant to 31
C.F.R. § 501.603(b) to fulfill their obligations under section 104(a) of the Act with respect to those assets and should not re-report to
OFAC any such assets under this instruction. Reports provided under this instruction shall identify Russian sovereign assets not
otherwise reported to OFAC pursuant to Directive 4 under Executive Order 14024 or in reports of blocked property filed pursuant to
31 C.F.R. § 501.603(b).

Date of
Detection
Value (USD)
Legal
Authority or
Authorities
Owner of
Property
Owner Type

The date the Russian sovereign asset was detected.

Description

A brief but comprehensive description of the Russian sovereign asset(s), 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 financial assets)

Location (city
and country)

List the location or branch where the property is held, if different from the address shown in Part A.

Provide the actual or estimated value of the property in U.S. Dollars as of the date of dection.
REPO Act Report
The person who legally owns the account or other property.
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.

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 93.09

Date of Detection

Value (USD) Legal Authority or Authorities

Owner of Property

Owner Type Asset Type Account Type(s)

Account Number(s)

Additional Description of the Property (if needed)

Location: City Location: Country