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

STATEMENT OF ACCESSORIAL SERVICES PERFORMED

OMB No. 0702-0022
OMB approval expires

This form is required only when accessorial services are chargeable to the Government. Carrier will enter complete information or
"None" in columns. "Unit Price" and "Charge" columns may be omitted when charges are itemized on the Standard Form 1113.

The public reporting burden for this collection of information is estimated to average 5 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, Executive Services Directorate, Information Management Division, 1155 Defense
Pentagon, Washington, DC 20301-1155 (0702-0022). 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 COMPLETED FORM TO THE ABOVE ORGANIZATION.
1. GOVERNMENT BILL OF LADING NUMBER

2. DATE OF PICKUP AT ORIGIN
(YYYYMMDD)

16. ACCESSORIAL SERVICES
PACKING, PACK MATERIALS AND UNPACKING
(1)

3.a. NAME OF OWNER (Last, First, Middle Initial)

NUMBER
(2)

UNIT PRICE
(3)

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0
0.00
0.00
0.00
0.00
0.00

a. DISH PACK
b. SSN

c. RANK OR GRADE

4. ORIGIN OF SHIPMENT

5. DESTINATION OF SHIPMENT

6.a. ORDERING ACTIVITY/INSTALLATION
NAME

b. LOCATION

7.a. NAME OF CARRIER

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

b. CARTONS (Less than 3 cubic feet)
c. CARTONS (3 cubic feet)
d. CARTONS (4-1/2cubic feet)
e. CARTONS (8 cubic feet)
f. CARTONS (8-1/2 cubic feet)
g. WARDROBE (Not less than 10 cubic feet)
h. MATTRESS, CRIB
i. MATTRESS (Not exceeding 39" x 75")
j. MATTRESS (Not exceeding 54" x 75")

8. SIGNATURE OF CARRIER'S REPRESENTATIVE

9. DATE
(YYYYMMDD)

k. MATTRESS (39" x 80")
l. MATTRESS (Exceeding 54" x 75")
m. TOTAL

10. CARRIER'S SHIPMENT REFERENCE NO.

11. AGENT OR DRIVER CODE

n. TOTAL SUBJECT MAX-PAK $

/cwt)

o. GRANDFATHER CLOCK CARTONS
LBS.

(2) STATE

b. SIT SERVICES PROVIDED AT (X one)
ORIGIN

DATES (YYYYMMDD):
c. IN

d. ORDERED OUT

h. REQUESTED DELIVERY
DATE (YYYYMMDD)

q. BOXES - WOODEN/CRATES (Not over 5 cu.ft.)
r. BOXES (Over 5 cu.ft./not over 8 cu.ft.)

13. STORAGE-IN-TRANSIT (SIT)
a. STORED AT (1) CITY

p. CORRUGATED CONTAINERS (Special constr.)

D R A F T

12. PROFESSIONAL BOOKS, PAPERS AND EQUIPMENT (PBP&E)
INCLUDED IN SHIPMENT (If not included, write "None".)

DESTINATION
OTHER
f. NUMBER g. NET WEIGHT
OF DAYS

e. DELIVERED OUT

s. BOXES (Over 8 cu.ft.) (Gross cu.ft.:

)

t. CRATES (Cubic feet:
(Minimum charge:

)

)

0.00
0.00

u. CARTONS, DOUBLE WALL (PPP-B-1364) &
TRIPLE WALL (PPP-B-640) (Not over 4 cu.ft.)

i. SHIPMENT ORDERED INTO AND OUT OF SIT ON DATES
INDICATED AND AUTHORIZED BY SIT CONTROL NO.

0.00
0.00
0.00

v. CARTONS (Over 4 cu.ft./less than 7 cu.ft.)
w. CARTONS (7 cu.ft./less than 15 cu.ft.)

j. WAS STORAGE POINT FOR CARRIER'S CONVENIENCE (X one)
14. REWEIGH CERTIFICATION (If applicable)
b. ORIGINAL GROSS
d. ORIGINAL TARE
f. ORIGINAL NET

0

YES

x. TOTAL PACKING CHARGE

NO

a. NUMBER
c. REWEIGH GROSS

y. LABOR (Describe service in "Remarks")
(Enter number of man-hours)

e. REWEIGH TARE

z. (X as applicable)

0

g. REWEIGH NET

15. APPLIANCES SERVICED (Owner/Agent must initial each entry separately.)
OWNER/AGENT
TYPE
MAKE/MODEL NO./MANUFACTURER
INITIALS
a.
b.
c.

EXTRA PICKUP

CHARGE
(4)

0.00

EXTRA DELIVERY

0.00

AUXILIARY SERVICES

0.00
0.00
0.00
0.00

aa. PIANO/ORGAN CARRY SERVICE
bb. ELEVATOR/STAIR/EXCESS DISTANCE
cc. SERVICING APPLIANCES/OTHER ARTICLES
(As itemized and initialed in Item 15)
dd. OTHER (Describe in "Remarks")

0.00

ee. TOTAL ACCESSORIAL SERVICE CHARGES
17. REMARKS

18. STATEMENT OF OWNER, MILITARY INSPECTOR/TRANSPORTATION OFFICER
a. MATERIALS WERE FURNISHED/ACCESSORIAL SERVICES WERE PERFORMED
OTHER (Explain)
AT ORIGIN

b. SIGNATURE (Do not sign until Carrier has completed column 16(2).)

c. DATE SIGNED
(YYYYMMDD)

AT DESTINATION
19. TRANSPORTATION OFFICER CERTIFICATION. I CERTIFY THAT SHIPMENT SERVICES WERE ACCOMPLISHED AS SHOWN BELOW.
a. SERVICES ACCOMPLISHED (X as applicable)
(1) ACCESSORIAL SERVICES (Listed in Item 16)
(2) STORAGE-IN-TRANSIT
b. SIGNATURE OF TRANSPORTATION OFFICER

DD FORM 619, 20080320 DRAFT

(3) REWEIGH CERTIFICATION

(6) WAITING TIME

(4) THIRD PARTY SERVICES
(5) BULKY ARTICLE CHARGE

(7) UNPACKING SERVICE (Baggage only)

(9) OTHER (Specify)

(8) OVERTIME LOADING/UNLOADING CHARGE
d. DATE SIGNED
(YYYYMMDD)

c. TITLE (Print or type)

PREVIOUS EDITIONS MAY BE USED.

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