0.340 (Rev. 41 I-0)) File Number Field Office Acquiring Evidence Serial f/ of Originating Document Date Received From ji/7 S//Los ^1 (Name of Contnbutorilnicrviorce) (Address) By 5-4 (City and State) To Re Returned 0 Yes IihNo Receipt Given 0 Yes Ilk No Grand Jury Material - Disseminate Only Pursuant