. 4-11- File Number Field Office Acquiring Evidence M.16— Serial II of Originating Document ra 1p Date Received 0 3// Pit Ote From (Name of Contributor/Intervievee) (Address) By r4 (City and State) To Be Returned 0 Yes a. No Receipt Given 0 Yes No Grand Jury Material - Disseminate Only Pursuant to Rul