Form DD Form 619 DD Form 619 Statement of Accessorial Services Performed

Prescribed by DTR 4500.9-R
OMB No. 0704-0531
OMB approval expires
May 31, 2025

STATEMENT OF ACCESSORIAL SERVICES PERFORMED

The public reporting burden for this collection of information is estimated to average three (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

2a. CUSTOMER NAME (Last, First, Middle Initial)

3a. ORIGIN OF SHIPMENT

2b. RANK/GRADE

3b. DATE OF PICKUP AT ORIGIN (DDMMYYYY)

3c. DESTINATION OF SHIPMENT

4. ORDERING ACTIVITY/INSTALLATION NAME

5. NAME OF TRANSPORTATION SERVICE
PROVIDER (TSP)

5a. TSP SHIPMENT REFERENCE
NUMBER

5b. NAME OF TSP REPRESENTATIVE (Last, First,

SCAC:
5c. SIGNATURE OF TSP REPRESENTATIVE

Middle Initial)

5d. DATE (DDMMYYYY)

6. TSP’s AGENT
6a. COMPANY NAME

6b. NAME OF AGENT REPRESENTATIVE (Last,
First, Middle Initial)

7. ADDITIONAL SERVICES (Enter additional details [as required] in Block 8, "Remarks")
7a. CRATES (Details required [e.g. number of crates & name of items])
7b. THIRD PARTY SERVICES (Details required [i.e., Schrank, Pool Table, etc.]; TSP must provide
invoice to PPSO.)

7c. SHUTTLE SERVICE (Details required)

7d. EXTRA PICKUP
7e. EXTRA DELIVERY
7f. OTHER (Details required)

8. REMARKS (Customer is required to initial next to each TSP additional service entry that apply.)

9. STATEMENT OF CUSTOMER
9a. MATERIALS WERE FURNISHED/ACCESSORIAL SERVICES WERE PERFORMED (X all that apply.)
ORIGIN
DESTINATION
OTHER (Details required in Block 8)
9b. CUSTOMER SIGNATURE (Do not sign until the TSP has provided an explanation for each additional service in Block 8, "Additional
9c. DATE (DDMMYYYY)
Services").

DD FORM 619, FEB 2025
PREVIOUS EDITION IS AUTHORIZED FOR USE UNTIL STOCK IS DEPLETED.