\N C,2_/Avos" Field Office Acquiring Evidence (Nek• ( 11‘. / s 11 &e Serial # of Originating Document Date Received V cul *s From (Name of Comnbutortinteresewee) (Address) Wm/ and Sta By Cl ic To Re Returned O Yes • .421clir Receipt Given O Yes Grand Jury Material - Disseminate Only Pursuant to Rul