DA Form 4919 "Request for Final Action"

What Is DA Form 4919?

This is a military form that was released by the U.S. Department of the Army (DA) on June 1, 2009. The form, often mistakenly referred to as the DD Form 4919, is a military form used by and within the U.S. Army. As of today, no separate instructions for the form are provided by the DA.

Form Details:

  • A 1-page document available for download in PDF;
  • The latest version available from the Army Publishing Directorate;
  • Editable, free, and easy to use;

Download an up-to-date fillable DA Form 4919 down below in PDF format or browse hundreds of other DA Forms stored in our online database.

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Download DA Form 4919 "Request for Final Action"

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REQUEST FOR FINAL ACTION
For use of this form, see AR 27-10; the proponent agency is OTJAG
GCM No.
SPCM No.
UNITED STATES, APPELLEE
V.
(Appellant)
SECTION A - APPELLANT'S REQUEST
I,
,
the undersigned accused, having received a copy of the decision of
(Name)
the United States Army Court of Criminal Appeals in the above entitled case on the
day of
having been fully advised as to my rights to petition the
,
,
(Day)
(Month)
(Year)
United States Army Court of Criminal Appeals for a grant of review with respect to any matters of law within 60 days under the provisions
of the Uniform Code of Military Justice, Article 67(c), and the Manual for Courts-Martial, United States, R.C.M. 1203, and having consulted
with legally qualified counsel and being informed that the sentence as affirmed by the United States Army Court of Criminal Appeals will
become final unless such a petition is filed, and having determined that I do not desire to petition for or prosecute an appeal to the United
States Court of Appeals for the Armed Forces, hereby request for my own convenience that appropriate action be taken to finalize the
affirmed sentence without further delay. I fully understand that this request will not operate to extend the period of 60 days in which I may
petition for a grant of review, that I may nevertheless so petition within the 60-day period notwithstanding this request. However, if I file a
timely petition for a grant of review after having executed this request, any action taken toward effecting my discharge from the Army in
reliance upon this request will be revoked, and in such case I will revert to my present status as a member of the Army and such status
will not be affected by any purported discharge issued in reliance upon this request.
SIGNATURE OF ACCUSED
DATE (YYYYMMDD)
SECTION B - COUNSEL'S DECLARATION
Prior to the signing of the foregoing request, I advised the above accused fully of his/her rights to petition the United States Court of
Appeals for the Armed Forces to review the decision of the United States Army Court of Criminal Appeals and to be represented by a
civilian lawyer provided at no expense to the United States, a detailed military lawyer, or both a civilian lawyer and detailed military lawyer.
TYPED NAME OF LEGALLY QUALIFIED COUNSEL
GRADE
SIGNATURE
DATE (YYYYMMDD)
DA FORM 4919, SEP 2002, IS OBSOLETE.
APD LC v1.00ES
DA FORM 4919, JUN 2009
REQUEST FOR FINAL ACTION
For use of this form, see AR 27-10; the proponent agency is OTJAG
GCM No.
SPCM No.
UNITED STATES, APPELLEE
V.
(Appellant)
SECTION A - APPELLANT'S REQUEST
I,
,
the undersigned accused, having received a copy of the decision of
(Name)
the United States Army Court of Criminal Appeals in the above entitled case on the
day of
having been fully advised as to my rights to petition the
,
,
(Day)
(Month)
(Year)
United States Army Court of Criminal Appeals for a grant of review with respect to any matters of law within 60 days under the provisions
of the Uniform Code of Military Justice, Article 67(c), and the Manual for Courts-Martial, United States, R.C.M. 1203, and having consulted
with legally qualified counsel and being informed that the sentence as affirmed by the United States Army Court of Criminal Appeals will
become final unless such a petition is filed, and having determined that I do not desire to petition for or prosecute an appeal to the United
States Court of Appeals for the Armed Forces, hereby request for my own convenience that appropriate action be taken to finalize the
affirmed sentence without further delay. I fully understand that this request will not operate to extend the period of 60 days in which I may
petition for a grant of review, that I may nevertheless so petition within the 60-day period notwithstanding this request. However, if I file a
timely petition for a grant of review after having executed this request, any action taken toward effecting my discharge from the Army in
reliance upon this request will be revoked, and in such case I will revert to my present status as a member of the Army and such status
will not be affected by any purported discharge issued in reliance upon this request.
SIGNATURE OF ACCUSED
DATE (YYYYMMDD)
SECTION B - COUNSEL'S DECLARATION
Prior to the signing of the foregoing request, I advised the above accused fully of his/her rights to petition the United States Court of
Appeals for the Armed Forces to review the decision of the United States Army Court of Criminal Appeals and to be represented by a
civilian lawyer provided at no expense to the United States, a detailed military lawyer, or both a civilian lawyer and detailed military lawyer.
TYPED NAME OF LEGALLY QUALIFIED COUNSEL
GRADE
SIGNATURE
DATE (YYYYMMDD)
DA FORM 4919, SEP 2002, IS OBSOLETE.
APD LC v1.00ES
DA FORM 4919, JUN 2009