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(~ C FD-340 (Rev, 4-11-03) File Number ___ Als ~ AME lox O62 —/A ial Field Office Acquiring Evidence | Serial # of Originating Document _—~ Date Received From (Name of Contributor/Interviewee} - {Address} ~ (City and State} To BeRetumed C1 Yes - Receipt Given [ Yes ; Grand Jury Material - Disseminate Only Pursuant to Rule 6 (e) Federal Rules of Criminal Procedure CI Yes Cl vte— Federal Taxpayer Information (FTD ; [1 Yes Cio Title: Reference: - {Comnfunication Enclosing Material) Sy, eo . t 03956-837 acd