-72 - 4031 - / 73 2 7 Field Office Acquiring Evidence M✓. - -L Serial # of Originating Document Date Received iyo 3/acv 9 From (Name of Conitibutorilmemeviee) (Address) By (City and Stale) To Be Be Retuned K Yes 0 No Receipt Given K Yes fa No Grand Jury Material • Disseminate Only Pursuant to R