DD Form 619 Statement of Accessorial Services Performed

Prescribed by DTR 4500.9-R
OMB No. 0704-0531
OMB approval expires:
XXXXXXXX

STATEMENT OF ACCESSORIAL SERVICES PERFORMED

The public reporting burden for this collection of information is estimated to average 3 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, at [email protected]. Respondents should be aware that
notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION.

1. BILL OF LADING NUMBER

2. OWNER NAME (Last, First, Middle Initial)

3. RANK/GRADE

4. ORIGIN OF SHIPMENT

5. DATE OF PICKUP AT ORIGIN (DDMMMYYYY)

6. DESTINATION OF SHIPMENT

7. ORDERING ACTIVITY/INSTALLATION NAME

8. SCAC/NAME OF TRANSPORTATION
SERVICE PROVIDER (TSP)

9. NAME OF AGENT

10. TSP SHIPMENT REFERENCE NO.

11. SIGNATURE OF TSP REPRESENTATIVE

13. ADDITIONAL SERVICES (Enter additional information in Item 14, "Remarks".)
a. CRATES (Indicate number of crates and name of item(s) in "Remarks".)
b. THIRD PARTY SERVICES (i.e., Schranks, pool table, etc. Must provide invoice to PPSO.)
c. SHUTTLE SERVICE (Describe in "Remarks".)

12. DATE (DDMMMYYYY)

d. EXTRA PICKUP
e. EXTRA DELIVERY
f. OTHER (Describe in "Remarks".)

14. REMARKS (Customer must initial next to each that apply.)

15. STATEMENT OF OWNER
a. MATERIALS WERE FURNISHED/ACCESSORIAL SERVICES WERE PERFORMED (X all that apply.)
ORIGIN

DESTINATION

OTHER (Explain in "Remarks".)

b. SIGNATURE (Do not sign until the TSP has explained ALL that apply in Item 13, "Additional Services".)

DD FORM 619, DRAFT 20220329

PREVIOUS EDITION IS AUTHORIZED FOR USE\

c. DATE (DDMMMYYYY)