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= FORM OBD-211 * : ; U.S. Department of Justice ' ‘ Request for Financial a (Authorization, Washington, D.C. 20330 Purchase Order, Receiving Report cot renee anaes e eee ee see reer RETR AE ORE LU cren SERaTe mecewerentnemrroerinbant z This form shail oaly be used when rgquesting finuaciol records of individuals and purmersbips of five or fewer individuals. Puschase Order Number: 2 Date Order Prepared, 3 va b3 -2 : . Section A - Authorization and Purchase Order TN — con. Lease include PVN# on payment: 6 Rectum Date: 7 Remarks: No Payment Shall Be Made Unless Expenses Are Itemized Below Or On Your Form To Be Attached. IL Service/Financial Records Provided Quantity Unit Pri Amount ————————— ———F = _————— I hereby certify that the services provided below were not performed relative b any corporation, joint ventug rain only}to accounts (checking, savings, share, loan, or credit card) of individual(s) or parmership(s) of five dr fewer partners. ae THE TAX IDENTIFICATION NUMBER FOR THE EINAND AI IN TION MUBT BE INCLUDED] HERE BEFORE PAYMENT CAN BE MADE, TAX IDENTIFICATION NUMBER: b3 -2 b6 -S SEARCH & PROCESSING pie 8 REPRODUCTION COST MAIL COST ioe iat: 13Dale Bigneds » Total Amount Claimed Z } By Financial Institution 16 Disallowance _ — (See Attached) 14 } certify that the articles and services listed were received: ° 15 Date Received: 17 Net io Financial : Instinution 18 Right to Financial Privacy Act - Public Law 95-630 19 Signature of Approving Official: {12 U.S.C, 3401-3422) Request Pursuant To: (Check One Only) OBJECT SECTION . CLASS (3404 Customer Authorization 2540 20 Accounting Classification Code () 3403 Administrative Subpoena or Summons . 2541 FYIFC pif 2 jf 3] [4 {5 | Pros] () 3406 Search Warrant 2542 Pr Q 3407 Judicial Subposna 2543 TELL ETEL LS (3408 Format Written Request 2344 21 Schedule and Voucher Number: (1D M13 1 Grand Jury Subpoena 2545 im 44t4 . Special Procedures 2546 DCE 22 Remarks: ” 03956-355