File Number Field Office Acquiring Evidence Serial # of Originating Document Date Received IC1/4"C \ lj t From 0 3 0 (op—. — Misie (Name of Conmbutorrintaysevece) (Address) By (City and State) To BeRetumed 0 Yes • EhNir— Receipt Given 0 Yes 0 -iC Grand Jury Material - Disseminate Only Pursuant to Rul