ev. 4.1 I-0 File Number Field Office Acquiring Evidence Serial 1$ of Originating Document Date Received a gist> '1 /2 0 p r"? From (Name of Conmbutor/Interviewce) (Address) (City and State) By • 574 To Be Returned 0 Yes B4No Receipt Given K Yes Q' No Grand Jury Material - Disseminate Only Pursuant