Approved OMB No. 1651-0055
Exp. 07/31/2018
1. Identifying Number
DEPARTMENT OF HOMELAND SECURITY
EIN or IRS
CBP
SSN
U.S. Customs and Border Protection
Number
Number
HARBOR MAINTENANCE FEE
2. Name of Company or Individual
AMENDED QUARTERLY SUMMARY REPORT
19 CFR 24.24
4. Identifying Number on Original Report
3. Complete Mailing Address
EIN or IRS Number
CBP Number
SSN
5. Reporting Period of Original Report
1
2
3
4
Year
(One Quarter Only)
6.
Reason for Amended Report
C.
Remit a Supplement Payment, because:
A.
Correction of Items 1-4
B.
Request for a Refund, because:
(1)
(1)
Calculation/Clerical Error
Calculation/Clerical Error
(2)
Duplication of Payment
(2)
Omission of Shipments
(3)
(3)
Misinterpretation of Exemptions
Misinterpretation of Exemptions
(4)
Overvaluation of Shipments
(4)
Overvaluation of Shipments
(5)
Other (Please Specify)
(5)
Other (Please Specify)
AMENDED PAYMENT CALCULATIONS
7.
8.
9.
10.
11.
Value of Shipments
Type of Shipment
Value of Exemptions
Net Value
HMF Due
(column 8 less column 9) (multiply the amounts in
With
(from corresponding
columns A-D of line 20)
Class Code
col. 10 by appropriate rate)
A. Domestic Movements
503
B. FTZ Admissions
505
C. Passengers
504
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D. Total Values (Total Column 8, 9, & 10)
$
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12. Total HMF Due (Total of Lines 11A through 11C)
$
13. Previous HMF Paid for this Reporting Period for this type Movement
. . . . . . . . . . . . . . . . . . . . . . . . . . .
$
. . . . . . . . . . . . . . . . . . .
Supplemental Payment, If line 12 is greater than line 13, enter difference
14. A.
Remit Payment to: CBP, Office of Finance, Revenue Division, 6650 Telecom Drive, Indianapolis, IN 46278
$
Refund Due. If line 13 is greater than line 12, enter difference.
. . . .
Mail refund request to: CBP, HMF
B.
$
Refunds, 6650 Telecom Drive, Suite 100, Indianapolis, IN 46278
ITEMIZATION OF EXEMPTIONS
A. Domestics
B. FTZ(s)
C. Passengers
D. Total
15. Exempt Port
16. Inland Waterway Fuel Tax
17. Intraport
18. U.S. Mainland/State/Possession/
Territory
19. Other
20. TOTALS (Also enter amounts in
$
$
$
$
19A thru 15C in 9A thru 9C above.)
21. CERTIFICATION
I hereby certify under penalties provided by law that the above information regarding the Harbor Maintenance Fee is complete and accurate to the best
of my knowledge.
Please Sign Here
Date
22. Type or print name of person who prepared this report (if same as block 2,
23. Telephone Number
write "SAME".)
PRIVACY ACT NOTICE: The following information is given pursuant of the Privacy Act of 1974 (Pub. L. 93-579). The disclosure of the social security number is mandatory when
an Internal Revenue Service number is not disclosed whenever an identification number is requested. Identification numbers are solicited under the authority of Excecutive Order
9397 and Pub. L. 99-662. The identification number provides unique identification of the party liable for the payment of the Harbor Maintenance Fee. The number will be used to
compare on this form with information submitted to the Government on other forms required in the course of shipping, exporting, or importing merchandise, which contain the
identification number, e.g., the SED, Vessel Operation Report, to verify that the information submitted is accurate and current.
Failure to disclose an identification number may
cause a penalty pursuant to 19 CFR 24.24(h).
PAPERWORK REDUCTION ACT NOTICE: This request is in accordance with the Paperwork Reduction Act. We ask for the information in order to carry out the Harbor
Maintenance Revenue provisions of the Water Resources Development Act of 1988. We need it to ensure that the trade community is complying with this Act, and to allow CBP to
determine if the correct amount of Harbor Maintenance Fee (HMF) is collected. It is mandatory. The estimated average burden associated with this collection of information is 30
minutes per respondent plus 10 minutes recordkeeping depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for
reducing this burden should be directed to U.S. Customs and Border Protection, Asset Management, Washington, DC 20229, and to the Office of Management and Budget,
Paperwork Reduction Project (1651-0055), Washington, DC 20503.
CBP Form 350 (03/09)