Form TD-F 93.02 TD-F 93.02 Report of Blocked Transactions

UNITED STATES DEPARTMENT OF THE TREASURY
OFFICE OF FOREIGN ASSETS CONTROL
REPORT OF BLOCKED TRANSACTIONS

INSTITUTION INFORMATION
INSTITUTION

TYPE OF INSTITUTION

ADDRESS

CITY

STATE

CONTACT PERSON

TELEPHONE NUMBER

POSTAL CODE

COUNTRY

E-MAIL ADDRESS

FAX NUMBER

TRANSACTION INFORMATION
AMOUNT BLOCKED
DATE OF TRANSACTION

DATE OF BLOCKING

PROGRAM OR REASON
FOR BLOCKING FUNDS

ORIGINATOR NAME & ADDRESS

ORIGINATING FINANCIAL INSTITUTION NAME &
ADDRESS

INTERMEDIARY FINANCIAL INSTITUTION(S) NAME &
ADDRESS

BENEFICIARY FINANCIAL INSTITUTION NAME &
ADDRESS

BENEFICIARY NAME & ADDRESS

ADDITIONAL RELEVANT INFORMATION (USE PAGE 2
IF MORE SPACE IS NEEDED)

ADDITIONAL DATA FOUND IN ORIGINATOR TO BENEFICIARY INFORMATION OR BANK TO BANK
INFORMATION

PLEASE ATTACH A COPY OF PAYMENT INSTRUCTIONS AS PAGE 3 OF THIS FORM
PREPARER INFORMATION
SIGNATURE
NAME OF SIGNER

TITLE OF SIGNER

DATE PREPARED

ADDITIONAL INFORMATION
(PLEASE INCLUDE PAYMENT INSTRUCTIONS AS A SEPARATE ATTACHMENT TO THIS DOCUMENT)