Rev. 4-11-03) File Number Field Office Acquiring Evidence Mtn Serial # of Originating Document itr Date Received 0410 q/2 On '7 From (Name ofCentributorfInterviewee) (Address) (City end State) By r.9 To Be Returned 0 Yes lir No Receipt Given 0 Yes a No Grand Jury Material - Disseminate Only Pursuant to R