loSemet€: in- (O) Field Office Acquiring Evidence Wit Serial # of Originating Document Sid • 58 to 01 ‘170scv Date Received From 17 (Name of Contributoranterviewec) (Address) To Be Returned 0 Yes No Receipt Given ' 0 Yes ICJ Grand Jury Material - Disseminate Only Pursuant to Rule 6 (e Federal Rules of Cr