le Number 31 E.-0\M- 105r oco)-. Field Office Acquiring Evidence Serial # of Originating Document c Date Received V O1.Y 'O(x S From (Name of Contributorflnterviewee) (Address) (Oct and State) By c selk To Be Returned 0 Yes ErNo Receipt Given 0 Yes Eng — Grand Jury Material - Disseminate Only pursuant to