Cbp Form 400 - Ach Application
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OMB No. 1651-0078
U.S. DEPARTMENT OF HOMELAND SECURITY
Bureau of Customs and Border Protection
ACH APPLICATION
Bureau of Customs and Border Protection Automated Clearinghouse Daily Statement Payment Program (This
application will be used to communicate account information to Mellon Bank)
Date:
Add
Change
Delete
Action to be Taken:
Current ACH Payer Unit Number:
RequestedEffectiveDate:
(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 filer 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 CBP Broker/Filer:
3 digit filer code:
Contact Name:
Telephone:
CBP ABI Client Representative of CBP 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:
Bureau of Customs and Border Protection
Telephone: (317) 298-1200 Ext. 1098
ACH Applications/Billings Section
FAX:
(317) 298-1259
ACH-Customs@customs.treas.gov
6026 Lakeside Blvd.
E-mail
Indianapolis, IN 46278
CBP Form 400 (02/04)
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