Form 7501A Document/Payment Transmittal

DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection

DOCUMENT/PAYMENT TRANSMITTAL
Transaction Number (e.g., entry or entry summary number, action number)
Entry Date

Summary Date

OMB 1651-0022
Exp. 08-14-2014

Importer of Record Number
Team Number

COLLECTION INFORMATION (Complete only if payment attached)
Code
(001) Duty
(499) MPF
(501) HMF
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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/XX)