Form 7501A Document/Payment Transmittal

DEPARTMENT OF HOMELAND SECURITY U.S. Customs and Border Protection OMB 1651-0022 Exp. XX-XX-XXXX DOCUMENT/PAYMENT TRANSMITTAL (7501A)
Transaction Number (e.g., entry or entry summary number, action number)			Importer of Record Number
Entry Date	Summary Date			Team Number
COLLECTION INFORMATION (Complete only if payment attached)
Code		Amount
(001) Duty
(499) MPF
(501) HMF
( )
( )
( )
( )
TOTAL
Comments:
An agency may not conduct or sponsor an information collection and a person is not required to respond to this information unless it displays a current valid OMB control number and an expiration date. The control number for this collection is 1651-0022. The estimated average time to complete this application is 15 minutes. If you have any comments regarding the burden estimate you can write to U.S. Customs and Border Protection, Office of Regulations and Rulings, 799 9th Street, NW, Washington DC 20229
CBP Form 7501A (XX/12)