5210/04 Agreement for Services (expert or Legal Support SErvices

POC

Save

Help

Import

Refresh

OMB NUMBER: 3064-0122
EXPIRATION DATE: 03/31/2007

Federal Deposit Insurance Corporation

AGREEMENT FOR SERVICES
EFFECTIVE DATE (MM/DD/YYYY)

AGREEMENT FOR SERVICES
(EXPERT/LEGAL SUPPORT SERVICES (LSS) PROVIDER)
RATE SCHEDULE

/

/

NOTE: If additional space is needed, complete and attach form FDIC 5210/04A, Agreement For Services (Expert/Legal Support Services (LSS) Provider) Rate Schedule Continuation Sheet. All
amendments to this Agreement For Services (Expert/Legal Support Services (LSS) Provider) Rate Schedule (i.e.: Name, Tax ID#, Address, Contact Person, Phone/Fax Number, Billable Individual,
Additions/Deletions) must be shown on the Agreement for Services (Expert/Legal Support Services (LSS) Amendment (form FDIC 5210/03).

SECTION I – EXPERT/LEGAL SUPPORT SERVICES PROVIDER INFORMATION
NAME OF EXPERT OR LEGAL SUPPORT SERVICES PROVIDER

FEDERAL TAX IDENTIFICATION NUMBER

BRANCH/OFFICE LOCATION (Each office of a multiple office firm/business must complete a separate Rate Schedule.)
ADDRESS

CITY

STATE

NAME OF CONTACT PERSON

ZIP CODE

PHONE NUMBER (Include Area Code)

E-MAIL ADDRESS
FAX NUMBER (Include Area Code)

MINORITY
STATUS
Asian American (A)
Black American (B)

BILLABLE INDIVIDUAL
(First, Middle, Last, Suffix)
Alphabetical Order

Hispanic American (H)
TITLE

Native American Indian (N)

GENDER
(M or F)

HOURLY
RATE

FIXED
RATE

SECTION II – SIGNATURES
SUBMITTED BY (Name and Signature of Expert/LSS Provider Authorized Representative) (Please sign)

TITLE

DATE SIGNED (MM/DD/YYYY)

NAME OF FDIC DELEGATED APPROVING OFFICIAL

TITLE

DATE SIGNED (MM/DD/YYYY)

SIGNATURE OF FDIC DELEGATED APPROVING OFFICIAL

LEGAL DIVISION OR OFFICE

EFFECTIVE DATE (MM/DD/YYYY)

PAPERWORK REDUCTION ACT NOTICE: Public reporting burden for this collection of information is estimated to average 1.0 hour per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to the Paper Reduction Act Clearance Officer, Legal Division, Room 3082, FDIC, 550 17th St. NW,
Washington, D.C. 20429, and to the Office of Management and Budget Paperwork Reduction Project (3064-0122), Washington, D.C. 20503. An agency may not conduct or sponsor, and a person
is not required to respond to, a collection of information unless it displays a currently valid OMB control number.
FDIC 5210/04 (10-05)