Number C 310 I.We 3027S71 0 Field Office Acquiring Evidence 10 7 Serial # of Originating Document Date Received Ei (21201, From (Name of Connibutortintaviewee) (Address) (City and State) By To Be Returned 0 Yes No Receipt Given 0 Yes Grand Jury Material - Disseminate Only Pursuant to Rule 6 (e)