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U.S. Department of Justice Request for Financial ormation (Authorization Washington, D.C. 20530 Furchase Order, Receiving Report) THLS EORM MST BE RILLED OUT AND RETIRNED FOR PAYMIENT Thys form shall ouly be used when requesning Finuocial records of individuals and purmersbips of five or f=wer indiniduals I Purchase Order Number. 12 Date Order Prepared. 3Case Number. b3 -2 Section A-Authorization and Purchase Order Please include PyN# on payment: 4Name and Address of Financi Insntion 5 D 6 Recm Date: 7 Remarks: 0 Dalg pf requgsl: b7c -2,-6 SectiodB-Finaacial Institution Invoice No Payment Shall Be Made Uniess Expcnses Are Jtemized Below Or On Your Fonm To Bc Attached. I! Service/Financial Records Pravided: Unit Price Quantity yunowy Cost I hereby certify tha the seryices provided below were not performed relative b any corporatjon, joint ventuges, etc., and pertain onlyto accounis. (checking, savings, share, loan, or credit card) of individual(s) or partnership(s) of five dr fewer partners. ITHE TAX IDENTIFICATION NUMBER FOR THE FINANCIAL. INSTITUTION MUST BE INCLUDED|HERE BEFORE PAYMIENT CAN BE b3 -2 MADE. TAX IDENTIFICATION NUMBER: b6 -5 b7C -5 SEARCH & PROCESSING REPRODUCTION COST MALL COST itution Officia DaleSig Total Amount Claimed By Financia Institution 16Disallowance Sectioa C - Receiving Report See Attached 14 1 certify that the articles and services listed were received: 15 Date Reccived: 17 Net i0 Financial Instirution 8 Right to Financial Prvacy Act -Public Law 95-630 9 Signature of Approving Official: (12 U.S.C.3401-3422 Request Pursuan1 To:(Check One Ony OBJECT SECTION CLASS 3404 Customer Authorization 2540 20 Accounting Classification Cods 3405 Administrative Subpoena or Summons 2541 FYFC 2 3 4 PROJ 3406 Scarch Warrant 2542 3407 Judicia! Subpoena 2543 1408 Formal Wrien Request 2544 21 Schedule and Voucher Number: 3413 1 Grand Jury Subpocna 2545 DC# 7 1414 Special Pracedures 2546 22 Ramarks: 03956-355 FORM OBD-711