DOJ-OGR-00029778.tif

(~ C i FD-340 (Rev. 4-11-03) File Number SS bl UM=" LOKO © 2-/A/AL - Field Office Acquiring Evidence \A 8 ra Serial # of Originating Document Date Received ACN o el From _ - (Name of Contributar/Interviewee) aan rere ‘ {Address} ~ . By To Be Returned [1 Yes - [No ReceiptGiven TL] Yes wae Grand Jury Material - Disseminate Only Pursuant to Rule 6 (2) Federal Rutes of Criminal Procedure . [Ll Yes Tito Federal Taxpayer Information (FTD 1 Yes Cae Title: Reference: (Comniunication Enclosing Material) ae Aelia ns Re or Clg ar rhe ; bic -2 DOJ-OGR- 00029778