Field Office Acquiring Evidence /AVM P RC Q.Ps Serial # of Originating Document Date Received \•1 t:t./‘ From 31 - los ocL - fig q3 (tame of Conutbutodaterviewee) (Address) (City and Sate) By To Be Returned 0 Yes CJ moo_ Receipt Given K Yes No Grand Jury Material - Disseminate Only Pursuant to Rule