ACH Application

Action to be taken:
If action is a change or a delete, please provide:
Current ACH Payer Unit Number:
Requested Effective Date:
If action is an add, change, or delete, please provide the following information:
Payer Company Name:
Payer Company Address:
Payer Contact Name:
Payer Telephone:
Please provide applicable importer number or 3 digit filer code of ACH applicant.
  Importer Number:
  OR 3 digit filer code:
  (include suffix)  
Bank Name:
Telephone 2:
Bank must be a National Automated Clearinghouse Association (NACHA) participant
ACH Bank Transit - Routing Number:
ACH Bank - Account Number:
To ensure the accuracy of the account information, it is requested that a specification sheet (obtained from your bank) be completed and accompany this application. The ACH payer will be held responsible for defaults which result from incomplete or erroneous account information when the specification sheet is not submitted and certified by bank personnel. Please verify that the bank transit routing and account numbers on the ACH application and specification sheet match before forwarding to the National Finance Center.
Name of Customs Broker/Filer:
  3 digit filer code:
  Contact Name:
U.S. Customs ABI Client Representative of Customs Broker/Filer:
Name of Authorizing Company Official:

Signature of Authorizing Company Official
(please type or print)
This application should be printed and faxed or mailed to the ACH coordinator at:
U.S. Customs Service
National Finance Center
ACH Applications
6026 Lakeside Blvd.
Indianapolis, IN 46278
Fax: (317) 298-1259
Phone: (317) 298-1200 Ext. 1098
(to be completed by the U.S. Customs Service)
ACH Payer Unit Number: (assigned by USCS)
  Effective Date: