Rev. 4-11.03) File Number Field Office Acquiring Evidence Serial # of Originating Document Date Received From 4,4O gyiadt. -) --MUM (ebutor/Intenviewee) (Address) (City and State) By To Be Returned 0 Yes Receipt Given 0 Yes (1/No Grand Jury Material - Disseminate Only Pursuant to Rule 6 (e)