ScreenShot Form 349

Approved OMB No. 1651-0055
Exp. 09-30-2008

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

1. Identifying Number

HARBOR MAINTENANCE FEE
QUARTERLY SUMMARY REPORT
19 CFR 24.24
Click for Instructions

EIN or IRS Number

CBP Number

SSN

2. Company Name
Individual Name

3. Complete Mailing Address

(Number and Street)

(State)

(Zip Code)

(Phone Number)

(Country)

Year

(One Quarter Only)

Type of Shipment With Class
Code
A. Domestic Movements

C. Passengers

(E-mail address)

Check here if address has changed since last filing.

(Fax Number)

4. REPORTING PERIOD

B. FTZ Admissions

(City)

(Number 2 and Street 2)

5.
Value of
Shipments

1st Quarter (Jan. 1 - Mar. 31)

3rd Quarter (Jul. 1 - Sep. 30)

2nd Quarter (Apr. 1 - Jun. 30)

4th Quarter (Oct. 1 - Dec. 31)

6.
Value of Exemptions (from
corresponding columns
A-D of line 15)

7.
Net Value (column
5 less column 6)

8.
HMF Due (multiply the amounts
in column 7 by appropriate rate)

C.
Passengers

D.
Total

503
505
504

D. Total Line Value 5, 6 & 7
9. Total HMF Due (Total of Lines 8A through 8C)..............................................................................................
ITEMIZATION OF EXEMPTIONS

A.
Domestics

B.
FTZ(s)

10. Exempt Port
11. Inland Waterway Fuel Tax
12. Intraport
13. U.S.
Mainland-State/Possession/
Territory
14. Other
15. TOTALS (amounts in 15A
thru 15D will automatically fill 6A
thru 6D above)

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16. 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
8-22-2008 Telephone Number
317-614-4458

6650 Telecom Drive
(Number and Street)

Indianapolis

(Number 2 and Street 2)

IN

46278

(City)
(State)
(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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CBP Form 349 (06/02)