Ach Application Form - U.s. Customs Service Page 2
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1
2
3Customs and Trade Automated Interface Requirements
Automated Clearinghouse
Data Element
Description
(ACH) Application Form
Bank Name
The name of the bank related to
bank account information.
The address of the bank related to
Address
A separate ACH Application Form must be
the bank account information.
completed for each bank account if multiple accounts
The telephone number of the bank
Telephone
are used in the Automated Clearinghouse (ACH). To
related to the bank account
receive notification of the assigned Payer’s Unit
information.
Number quickly, print the FAX telephone number in
A 9-position number identifying
ACH Bank
the upper right-hand corner of the form. If a broker
the location of the bank where the
Transit
is providing the form on behalf of the client, the
bank account is located. This
Routing
client’s FAX number should be provided.
number is obtained from the bank.
Number
It is the responsibility of the payer
Definitions for the data elements reported on the
to ensure that the information
ACH Application Form are defined below:
provided is correct.
The bank account number which
ACH Bank
Data Element
Description
is to be used in the ACH payment
Account
process. This number is obtained
Number
Add
Check this box if the action is to
from the bank.
It is the
add new banking account data.
responsibility of the payer to
Change
Check this box if the action is to
ensure
that
the
information
change banking account data
provided is correct.
already on file or to change
The
name
of
the
Customs
Name of
company
address
or
contact
Broker/Filer the payer will use in
Customs
information.
Broker/Filer
the ACH payment authorization
Delete
Check this box if the action is to
transmission. If payer uses more
delete the ACH payer’s unit
than one Customs Broker/Filer,
number. Deleting the record will
provided the name of only one.
prevent its future use in the ACH
The filer code of the related
3-Digit Filer
payment authorization transaction.
Customs Broker/Filer the payer
Code
Current ACH
The current ACH payer unit
will sue in the ACH payment
Payer Unit
number for which the change or
authorization transmission.
Number
delete is requested.
Contact Name
The name of a contact person of
The date the change is to take
Requested
the related Customs Broker/Filer
place. Effective dates for changes
Effective Date
name.
should be at least two business
The telephone number of the
Telephone
days in the future.
related
Customs
Broker/Filer
Payer
The name of the company which
contact name.
Company
relates to
the
bank
account
U.S. Customs
The name of the ABI Client
information being provided.
Name
Representative
of
the
related
ABI Client
The city, state and ZIP code of the
Payer
Customs Broker/Filer the payer
Representative
company which relates to the
Company
of Customs
will use in the ACH payment
Address
bank account information being
Broker/Filer
authorization transmission.
provided.
Name of
The name of the company official
Payer Contact
The name of the contact person
Authorizing
who is authorized to release the
for the related payer company
Name
information provided on the form.
Company
name.
Official
The telephone and FAX number
Payer
Signature of
A
legible
signature
of
the
Telephone/
of the company responsible for
Authorizing
company
official
who
is
FAX
the ACH payment.
Company
authorized
to
release
the
Importer
The 12-position importer number
Official
information on the form.
or
the 3-position
filer
code
Number or
identifying the payer to which the
3-Digit Filer
ACH payer unit number will be
Code
assigned.
J-4
Appendix J
Amendment 2 - January 2002
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