Form CBP Form 400 CBP Form 400 ACH Debit Application

OMB No. 1651-0078
Expiration: 10-31-2017

DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection
ACH DEBIT APPLICATION

U.S. Customs and Border Protection Automated Clearinghouse Daily Statement Payment Program
(This application will be used to communicate account information to Federal Reserve Bank of Cleveland)
Add
Action to be Taken:

Change

Effective Date:

Current Payer Unit Number:

Delete

Effective Date:

Current Payer Unit Number:

(Effective date should be at least 3 business days in the future)

Payer Information
Payer Importer Number OR 3 digit filer code:
(Include Suffix)

Payer Company Name:
Payer Company Address:
Payer City, State Zip:
Payer Contact Name:
Payer Email Address:
Payer Telephone:

FAX:
(Enter country code if applicable)

Name of Authorizing Company Official (Please type or print)

(Enter country code if applicable)

Signature of Authorizing Company Official

Banking Information
Bank must be a National Automated Clearinghouse Association (NACHA) participant.
Bank Name:

Address:

ACH Bank Transit
Routing Number:

ACH Bank
Account Number:

To ensure the accuracy of the account information, it is requested that written verification (obtained from your bank) be completed and
accompany 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 ensure that the bank transit routing and
account numbers on the ACH application have been verified by your bank before sending to the Revenue Division.

Broker/Filer Information
Name of CBP Broker/Filer:

3 digit filer code:

Contact Name:

Telephone:

Fax:

ABI Representative of Customs Broker/Filer:
This application may be faxed, mailed or e-mailed to the ACH Coordinator at:
Revenue Division
ACH Debit Applications
6650 Telecom Drive, Suite 100
Indianapolis, IN 46278

Telephone: (317) 298-1200 Ext. 1098
FAX:
(317) 298-1259
Email:

[email protected]

Paperwork Reduction Act Statement: 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 1651-0078. The estimated average time to complete this application is 5 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, 90 K Street, NE., Washington DC
20229.

CBP Form 400 (02/12)