OMB No. 1505-0164
TD-F 93.02
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
