Application for access to and/or rectification, erasure or blocking of personal data held pursuant to the U. S. Terrorist Finance Tracking Program (tftp) Form c – Article 16 Rectification, Erasure or Blocking Request




Дата канвертавання19.04.2016
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Application for access to and/or rectification, erasure or blocking of personal data held pursuant to the
U.S. Terrorist Finance Tracking Program (TFTP)

Form C – Article 16 Rectification, Erasure or Blocking Request

1. Surname / Family name:


2. First Name(s):


3. Maiden / Other names:


4. Residential Address:


5. Bank Name(s):

6. Bank Address(es):


7. Account Number(s):

8. Please provide: (a) a precise identification of the record that you believe to be inaccurate or to have been processed in contravention of the TFTP Agreement, including a description of the record, the date and any other identifying details; (b) the specific material to be amended, deleted, or blocked, if any, including a citation of the specific paragraph, sentence, and word to be amended, deleted, or blocked; (c) a statement regarding why the information is not accurate or complete, including supporting evidence; and (d) the specific material to be added, if any, and the exact place at which it is to be added, including evidence of the validity of new or additional information. If you wish to correct or add any information, you must provide specific proposed language for the desired correction or addition. Finally, indicate whether you have contacted your financial institution seeking rectification, deletion, or blocking of any information you believe to be inaccurate and, if so, how the financial institution responded.



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Signature of the Requester Date
Signature of the National DPA Date


Further information may be provided in a separate letter. If a separate letter is provided, please state explicitly if you authorize to transfer the information in that letter to the U.S. Treasury Department






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