Field Office Acquiring Evidence Sl 2_ - Ats8b40-?-- - /A 0-3 km.) Pi3c-F—Pc Serial # of Originating Document Date Received n S From Name or ContributodInterviewce) (Address) (City and State) By To Be Returned 0 Yes • B - to Receipt Given ii Yes Grand Jury Material- Disseminate Only Pursuant to Rule 6