(Rev 4 II 03) File Number ad. Field Office Acquiring Evidence Serial # of Originating Document / 417 Dafe Received 040-selan From (Name of Cuntnbu to:. In ten itwee) (Address) (City and Statc) BY --a 'In Be Returned 0 Yes • EF-•No Receipt Given 0 Yes EY No 060 Jury Material - Dissemina