Transportation Indemnity Service

550 N. Main Street
Logan, UT 84321
(435)787-9300

Sample Form

LOGISTICS DISCREPANCY SYSTEM REPORT

* Required Information

SHIPMENT IDENTIFICATION:

* PO or SO No.

Tracking No.

* Origin:

( Purchase Order or Shipping Order Number )

* Destination:

( Complete Name, Street Address, City, State & Zip Code )

Trailer/Container No:

( Complete Name, Street Address, City, State & Zip Code )

Load No.

FB or DR No:

(Freight Bill or Delivery Receipt Number)

Destination Seal No:

Intact

Invoice or B/L No:

* Received Date:

( MM/DD/YY - 12/25/03 )

* Carrier:

SHIPMENT DETAILS:

Cases Shipped:

Cases Received:

Units Shipped:

Units Received:

Distribution Center Identifier:

	Shortage		Damage
	Proof of Tampering		Pictures Taken

Exception Taken on Delivery Receipt

Cost per Unit $:

Cost per Case $:

ADDITIONAL DETAILS:

( Describe the Nature
& Extent of damages; ex: 4cs wet, 7 cs crushed - unsaleable) SEE INSTRUCTIONS FOR EXPLANATION

SENDER INFORMATION:

* Your name:

Your Office Phone:

* Your e-mail address:

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