OMB No. 1505-0164
TD-F 93.07
REPORT ON REJECTED TRANSACTION*
(Use of this form is optional, but the information requested is required by 31 C.F.R. § 501.604)
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 REJECTION
TYPE OF TRANSACTION (e.g., wire transfer,
account, letter of credit, check, securities)
LEGAL AUTHORITY OR AUTHORITIES FOR
REJECTING (e.g., 31 C.F.R Part 560)
SANCTIONS TARGET / NEXUS (e.g., sectoral
sanctions target or commercial activity with Cuba,
Iran, Syria, Crimea)
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 certain rejected transactions, 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 blocked property, please use form “Report on Blocked Property – Tangible/Real/Other Non-financial Property” (Form TD-F 93.08) or
“Report on Blocked Property – Financial” (Form TD-F 93.02), whichever is applicable.
PLEASE INCLUDE A COPY OF ANY PAYMENT OR TRANSFER INSTRUCTIONS OR OTHER RELEVANT
DOCUMENTATION AS A SEPARATE ATTACHMENT
