1143) File Number 12- -PI - 113 3 n--/ A 14 Field Office Acquiring Evidence Serial # of Originating/ Document Date Received t ) From (Name of Contributondnternewee) (Address) (City 2nd State) By To Be Returned 0 Yes 0 No Receipt Given 0 Yes 0 No Grand Jury Material - Disseminate Only Pursuant to Rule 6 (