5210/03 Agreement for Services (Expert Legal Support Services (L

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OMB NUMBER: 3064-0122
EXPIRATION DATE: 03/31/2007
AGREEMENT FOR SERVICES
EFFECTIVE DATE (MM/DD/YYYY)
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Federal Deposit Insurance Corporation

AGREEMENT FOR SERVICES
(EXPERT/LEGAL SUPPORT SERVICES (LSS) PROVIDER)
AMENDMENT

/

SECTION I – EXPERT OR 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

E-MAIL ADDRESS

PHONE NUMBER (Include Area Code)

FAX NUMBER (Include Area Code)

MINORITY
STATUS
Asian American (A)
ADD (A)
or
DELETE (D)

Black American (B)

BILLABLE INDIVIDUAL

Hispanic American (H)

(First, Middle, Last, Suffix)
Alphabetical Order

TITLE

Native American Indian (N)

GENDER
(M or F)

HOURLY
RATE

FIXED
RATE

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

TITLE

DATE SIGNED (MM/DD/YYYY)

FDIC DELEGATED APPROVING OFFICIAL (Please print or type)

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
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
aspect of this collection of information, including suggestions for reducing this burden to the Paper Reduction Act Clearance Officer, Legal
550 17th Street N.W., Washington, DC 20429, and the Office of Management and Budget, Paperwork Reduction Project (3064-0122).
required to respond to, a collection of information unless it displays a currently valid OMB control number.
FDIC 5210/03 (10-05)

per response, including the time for reviewing instructions,
Send comments regarding this burden estimate or any other
Division, Room 3082, Federal Deposit Insurance Corporation,
An agency may not conduct or sponsor, and a person is not