(Rev. 4-It 43) File Number e 77.-A4144-03-321 Field Office Acquiring Evidence Serial # of Originating Document Date Received From (Name of Contautonintamvico (Address) Ct and State) By To Be Retuned 0 Yes 0 No Receipt Given 0 Yes 0 No Grand Jury Material - Disseminate Only Pursuant to Rule 6 (e)