/3 (I Field Office Acquiring Evidence 1‘-' Pk IP BC iz Pr • Serial f of Originating Document Date Received \I /A -('l 0 Li S From (Name of Ccatributot/Intmiewee) (Address) (City and State) BY t_ To Be Returned D Yes E3—Ffr Receipt Given 0 Ycs Errsicr Grand Jury Material - Disseminate Only Pursuant