5210/03A Agreement for Services (Expert or Legal Support Services

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OMB NUMBER: 3064-0122
EXPIRATION DATE: 03/31/2007
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Federal Deposit Insurance Corporation

AGREEMENT FOR SERVICES
(EXPERT/LEGAL SUPPORT SERVICES PROVIDER)
AMENDMENT (Continuation Sheet)

Page

of

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

BILLABLE INDIVIDUAL

Black American (B)

(First, Middle, Last, Suffix)
Alphabetical Order

Hispanic American (H)
TITLE

Native American Indian (N)

GENDER
(M or F)

HOURLY
RATE

FIXED
RATE

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, Federal Deposit Insurance
Corporation, 550 17th Street, N.W., Washington, DC 20429, and 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 5210/03A (10-05)