EFTA00130073 FD-340c(4-11-03) File Number 90A-NU-3151227 Field Office Acquiring Evidence NYO Date Received 8-28-2019 From \textcircled{O} C M E [Name of Contributor/Interviewee] [Address] By To Be Returned □ Yes □ No Receipt Given □ Yes □ No Grand Jury Material - Disseminate Only Pursuant to Rule 6 (e) Federal Rules of Criminal Procedure ☐ Yes ☐ No
| Federal Taxpayer Information (FTI) | ||
| ☐ Yes | ☐ No | |