Free CBP Form 400 - ACH Application - Federal

DEPARTMENT OF HOMELAND SECURITY

OMB No. 1651-0078 Exp. 10-31-2011

U.S. Customs and Border Protection ACH APPLICATION
U.S. Customs and Border Protection Automated Clearinghouse Daily Statement Payment Program (This application will be used to communicate account information to Federal Reserve Bank of Cleveland) Date: Action to be Taken: Add Change Delete Requested Effective Date:
(Effective date should be at least 3 business days in the future)

Current ACH Payer Unit Number:

Payer Company Name: Payer Company Address:

Payer Contact Name: Payer Email Address: Payer Telephone:
(Enter country code if applicable)

FAX:
(Enter country code if applicable)

Importer Number: (Include suffix) Bank Name: Bank Telephone Number: Address:

OR 3 digit filer code:

Bank must be a National Automated Clearinghouse Association (NACHA) participant. ACH Bank Transit Routing Number ACH Bank Account Number

To ensure the accuracy of the account information, it is requested that written verification (obtained from your bank) be completed and accompany this application. The ACH payer will be responsible for defaults, which result from incomplete or erroneous account information when written verification is not submitted and certified by bank personnel. Please ensure that the bank transit routing and account numbers on the ACH application have been verified by your bank before sending to the Revenue Division.

Name of CBP Broker/Filer: Contact Name: U.S. Customs and Border Protection ABI Client Representative of Customs Broker/Filer:

3 digit filer code: Telephone:

Name of Authorizing Company Official (Please type or print) This application may be faxed, mailed or e-mailed to the ACH Coordinator at: Revenue Division ACH Debit Applications 6650 Telecom Drive, Suite 100 Indianapolis, IN 46278

Signature of Authorizing Company Official

Telephone: (317) 298-1200 Ext. 1098 FAX: (317) 298-1259 [email protected] Email:

CBP Form 400 (06/09)