DOJ-OGR-00029505.tif

iv - FD-340 (Rev. 4-11-03) | ; | - File Number 3 lE-Wm™ NOkOG2. -/A/05 : . Field Officé Acquiring Evidence AMM /PRCLA | Serial # of Originating Document __~ on Date Recefyed _\Jewronsy From _ | (Name of Contributor/Interviewee} ‘ (Address} ~ ~ | ToBeRetumed (1 Yes - Erno : Receipt Given [1 Yes Tee i Grand Jury Materiat - Disseminate Only Pursuant to Rule 6 {e) ' Federal Rules of Criminal Procedure . ; [I Yes TK Federal Taxpayer Information (FID LI Yes [INo Title: ) ‘ Reference: {Comniunication Enclosing Material) Ne Description: 1] Original notes re interview of 03956-7190 "\ . pce DOJ-OGR-00029505