40 (Rer. 4.11-0J) 1 File Number e Amer\ -1(xv6P- Field Office Acquiring Evidence Serial # of Originating Document Date Re From moa (1)E.)Q,{64- Contn ear/interviewee) (Address) By ' 1 To Be Returned 0 Yes No Receipt Given 0 Yes 0-141 Grand Jury Material - Disseminate Only Pursuant to Ru