DOJ-OGR-00029285.tif

(~~ FD-340 (Rev. 4-11-03) File Number S3ls- - |OX0G2-/P3 Field Office Acquiring Evidence Me] Paces | ; Serial # of Originating Document __~ Date Received _ Wiertisoo From (Name of Contributar/Interviewee) {Address} (City and State) By To BeRetumed C) Yes - Receipt Given (1 Yes Peto Grand Jury Material - Disseminate Only Pursuant to Rule 6 (e) Federal Rules of Criminal Procedure [] Yes ita Federal Taxpayer Information (FT) [J Yes [1Ne— Title: Reference: (Comniunication Enclosing Material} en Description: [i Original notes re interview of DOJ-OGR-00029285