0 D‘___—//4/3?-- j Field Office Acquiring Evidence k @A P (2) citioic Serial # of Originating Document Date Received Pc ek.&t..) S From (Name orContnbutodInteramme) (Address) • (City and State) By To Be Returned 0 Yes • CNo Receipt Given 0 Yes [Thlyro-- Grand Jury Material - Disseminate Only Pursuant