EFTA00129659





C 1A5

FD-340 (Rev. 4-11-03)

File Number 72-MM-113327 -1A8

Field Office Acquiring Evidence 11/18/2009

Serial # of Originating Document ___

Date Received ___

[Name of Contributor/Interviewee]

[Address]

By \underline{SA}

## (City and State)

To Be Returned ☐ Yes ☐ No

Receipt Given □ Yes



□ No



Receipt Given

Grand Jury Material - Disseminate Only Pursuant to Rule 6 (e)

Federal Rules of Criminal Procedure

<table><tr><td>Yes</td><td>No</td></tr><tr><td>Federal Taxpayer Information (FTI)</td><td></td></tr><tr><td>Yes</td><td>No</td></tr></table>

Title:

Description: Original notes re interview of @ GJ Subpoena results for phone number