Ach Application Form - U.s. Customs Service
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1
2
3Customs and Trade Automated Interface Requirements
ACH Application
ACH APPLICATION
United States Customs Service Automated Clearinghouse Daily Statement Payment Program
(This form will be used to communicate account information to Mellon Bank)
Date: ____________________
Add �
Change �
Delete �
Action to be taken:
Current ACH Payer Unit Number: _____________________ Requested Effective Date: ___________________
(Allow at least two business days.)
Payer Company Name:
______________________________________________________________________
Payer Company Address: ______________________________________________________________________
______________________________________________________________________
Payer Contact Name:
______________________________________________________________________
Payer Telephone:
(
)
____________________
FAX: (
) __
_________________
Importer Number: ______________________________
OR 3 digit filer code: __ __ _
_
(include suffix)
Bank Name: _________________________________
Address: ____________________
Telephone: (
)
______________________________
Bank must be a National Automated Clearinghouse Association (NACHA) participant.
ACH Bank Transit
ACH Bank
Routing Number: _ _ _ _ _ _ _ _ _
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 that result from incomplete or
erroneous account information when written verification is not submitted and certified by bank personnel. Please verify that the
bank transit routing and account numbers on the ACH application and bank specifications sheet match before forwarding to the
Accounting Services Division.
Name of Customs Broker/Filer: ____________________
3 digit filer code: __ __ __
Contact Name: ______________________________
Telephone: (
)
________________
U.S. Customs ABI Client Representative of Customs Broker/Filer ____________________
______________________________________________
________________________________________
Name of Authorizing Company Official
Signature of Authorizing Company Official
(Please type or print)
This application should be faxed, mailed or e-mailed to the ACH Coordinator at:
U.S. Customs Service
Telephone:
(317) 298-1200 Ext. 1098
ACH Applications
FAX:
(317) 298-1259
P.O. Box 68901
Indianapolis, IN
46268
Email: ACH-Customs@customs.treas.gov
This section to be completed by the U.S. Customs Service
ACH Payer Unit Number _ _ _ _ _ _ (assigned by USCS) Effective Date __________________________
(Effective date is the first date ACH payment authorizations may
be sent by Customs Broker/Filer)
Amendment 2 - January 2002
Appendix J
J-3
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