DD Form 619-1 Statement of Accessorial Services Performed (Storage-In-

OMB No. 0702-0022
OMB approval expires

STATEMENT OF ACCESSORIAL SERVICES PERFORMED
(STORAGE-IN-TRANSIT DELIVERY AND REWEIGH)

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.
DISTRIBUTION:

1. ORIGINAL COPY TO CARRIER.
2. COPY TO PROPERTY OWNER.

1. GOVERNMENT BILL OF LADING
NUMBER

3. ADDITIONAL COPIES MAY BE MADE FOR CARRIER'S USE.

2. DATE OF PICKUP AT ORIGIN
(YYYYMMDD)

13. STORAGE-IN-TRANSIT (SIT)
b. SIT SERVICES WERE PROVIDED
AT (X as applicable)

a. STORED AT (City and State)

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

DESTINATION

b. SSN

c. RANK OR GRADE

4. ORIGIN OF SHIPMENT

5. DESTINATION OF SHIPMENT

6.a. ORDERING ACTIVITY/
INSTALLATION NAME

b. LOCATION

c. DATE IN
(YYYYMMDD)

d. DATE OUT
(YYYYMMDD)

e. NUMBER
OF DAYS

g. THIS SHIPMENT WAS ORDERED INTO AND OUT OF SIT ON DATES
INDICATED HEREON AND AUTHORIZED BY SIT CONTROL NUMBER:

SIT IN EXCESS OF 90 DAYS WAS AUTHORIZED (X)
h. SIGNATURE OF TRANSPORTATION OFFICER

7.a. NAME OF CARRIER

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

8. SIGNATURE OF CARRIER'S REPRESENTATIVE

9. DATE
(YYYYMMDD)

11. AGENT OR DRIVER CODE

YES

NO

i. DATE
(YYYYMMDD)

14. REWEIGH CERTIFICATION
a. ORIGINAL GROSS

b. REWEIGH GROSS

c. ORIGINAL TARE
10. CARRIER'S SHIPMENT REFERENCE NO.

OTHER
f. NET WEIGHT

e. ORIGINAL NET

d. REWEIGH TARE

0

0

f. REWEIGH NET

g. THIS SHIPMENT WAS ORDERED FOR REWEIGH AND SERVICES WERE
ACCOMPLISHED AS SHOWN ABOVE.

12. REMARKS

D R A F T

(1) SIGNATURE OF TRANSPORTATION OFFICER

15. ADDITIONAL SERVICES

(1) NUMBER

(2) DATE
(YYYYMMDD)

(2) UNIT PRICE

(3) CHARGE

a. LABOR - NUMBER OF MANHOURS (Describe services in
"Remarks")

0.00

b. PIANO/ORGAN OR
EXCESS CARRY SERVICES

0.00

c. OTHER (Describe in
"Remarks")

0.00

16. CONSIGNEE'S STATEMENT OF DELIVERY AND LOSS OR DAMAGE
Notice is hereby given to the carrier to whom this statement of accessorial services performed is surrendered that the shipment was received in
condition as shown below and that claim, if any, will be made for the value of such loss and/or damage as indicated.
a. DESCRIPTION OF LOSS OR DAMAGE

17. WAIVER
Unpacking and removal of packing material,
boxes/cartons, and other debris is hereby waived.

a. INVENTORY NUMBERS

b. ACTUAL OR ESTIMATED WEIGHT

b. SIGNATURE

18. CERTIFICATION. I have received the property described on this form:
a. FROM (Name of Transportation Company)

b. AT (Actual Point of Delivery)

c. SIGNATURE OF CONSIGNEE OR AUTHORIZED AGENT

DD FORM 619-1, 20080320 DRAFT

in apparent good order and condition
except as noted above.
d. DATE OF DELIVERY (YYYYMMDD)

PREVIOUS EDITIONS MAY BE USED.

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