i3.340 (Rev. 4.11.03) File Number 72--Pusi\-- 1133- 7 -1113 Field Office Acquiring Evidence Serial # of Originating Document MAD A 9 (Name of Contnbutor/Iniernewee) (Address) Ca end Stale) By To Be Returned 0 Yes 0 No Receipt Given 0 Yes 0 No Grand Jury Material - Disseminate Only Pursuant to Rule 6