EFTA Document EFTA01338369

FD-340 (Rev. 4•I I -O3) File Number -72 - 4031 - / 73 2 7 Field Office Acquiring Evidence M✓. - -L Serial # of Originating Document Date Received iyo 3/acv 9 From (Name of Conitibutorilmemeviee) (Address) By (City and Stale) To Be Be Retuned K Yes 0 No Receipt Given K Yes fa No Grand Jury Material • Disseminate Only Pursuant to Rule 6 (e) Federal Rules of Criminal Procedure K Yes S No Federal Taxpayer Information (FTI) K Yes 1 2 No Title: Reference: (Common