ScreenShot (Form 350)

Approved OMB No. 1651-0055

DEPARTMENT OF HOMELAND SECURITY
U.S. Customs and Border Protection

HARBOR MAINTENANCE FEE
AMENDED QUARTERLY SUMMARY REPORT
19 CFR 24.24

Exp. 09-30-2008

1. Identifying Number

EIN or IRS Number

CBP Number

SSN

2. Company Name
Individual Name

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3. Complete Mailing Address
(Number and Street)
(State)

(City)

(Number 2 and Street 2)

(Zip Code)

(Country)

(Phone Number)

(E-mail address)
Check here if address has changed since last filing.

(Fax Number)

4. Identifying Number on Original Report
EIN or IRS Number

5. Reporting Period of Original Report

CBP Number

Year

SSN

(One Quarter Only)

1

3

2

4

6. Reason for Amended Report
A. Correction of Items 1-4

7. Type of Shipment With
Class Code

A. Domestic Movements
B. FTZ Admissions
C. Passengers

B. Request for a Refund, because:

C. Remit a Supplement Payment, because:

1. Calculation/Clerical Error

1. Calculation/Clerical Error

2. Duplication of Payment

2. Omission of Shipments

3. Misinterpretation of Exemptions

3. Misinterpretation of Exemptions

4. Overvaluation of Shipments

4. Overvaluation of Shipments

5. Other (Please Specify)

5. Other (Please Specify)

8. Value of
Shipments

9. Value of Exemptions
(from corresponding
columns A-C of line 20)

10. Net Value
(column 8 less
column 9)

11. HMF Due (multiply
the amounts in column
10 by appropriate rate)

503
505
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...........................................................
14. A. Supplemental Payment. If line 12 is greater than line 13, ........................................................................
B. Refund Due. If line 13 is greater than line 12, ........................................................................................
ITEMIZATION OF EXEMPTIONS

A. Domestics

B. FTZ(s)

15. Exempt Port
16. Inland Waterway Fuel Tax
17. Intraport
18. U.S. Mainland/State/Possession/
Territory
19. Other
20. TOTALS (amounts in 20A thru
20C will automatically fill 9A thru 9C
above)

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C. Passengers

D. Total

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.
Signature

Nannette Voll

Date

Telephone Number

317-614-4458

6650 Telecom Drive
(Number and Street)

(Number 2 and Street 2)

Indianapolis

IN

(City)

(State)

46278
(Zip Code)

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 Executive 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).
PAPER WORK 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, Information Services Division, Washington,
DC 20229, and to the Office of Management and Budget, Paperwork Reduction Project (1651-0055), Washington, DC 20503.

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Submit Data

CBP Form 350 (06/02)

After submitting the HMF 350 form, you will need to either fax or e-mail the supporting documents for the original HMF 349 form and the
supporting documents for the change(s) reflected on the HMF 350 form. Also, include a copy of the original HMF 349 form and the HMF
350 form submitted. On all of the documents sent, record the Pay.gov Tracking ID received when the HMF 350 form was submitted in Pay.
gov. Fax the documents to either 317-298-1259 or 317-298-1071 or e-mail the documents to [email protected] with the subject line "HMF 350
Supporting Documents".