OMB No. 1515-0218
DEPARTMENT OF THE TREASURY
United States Customs Service
ACH APPLICATION
United States Customs Service Automated Clearinghouse Daily Statement Payment Program
(This application will be used to communicate account information to Mellon Bank)
Date: _____________________
Action to be Taken:
Add
Change
Delete
Current ACH Payer Unit Number: ______________________ Requested Effective Date: __________________
(Effective date should be at least 2 business days in the future)
Payer Company Name:
__________________________________________________________________________
Payer Company Address: ___________________________________________________________________________
___________________________________________________________________________
Payer Contact Name:
___________________________________________________________________________
Payer Telephone: (______)______________________________
FAX: (______)_________________________
Importer Number:
__________________________
OR 3 digit filler code: ___________________
(Include suffix)
Bank Name: _____________________________________________________________________________________
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
accompanies 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 verify that the bank transit routing and
account numbers on the ACH application and verification from your bank match before sending to the Accounting Services Division.
The payer unit number assigned for your ACH account is valid for any broker who files entries on your behalf. Please list one broker on
the line below.
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 may 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
ACH-Customs@customs.treas.gov
6026 Lakeside Blvd.
E-mail
Indianapolis, IN 46278
Customs Form 400 (081099)