5210/04A Agreement for Svcs (Expert/Legas Support Svcs) Provider

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

Federal Deposit Insurance Corporation

Page

of

AGREEMENT FOR SERVICES
(EXPERT/LEGAL SUPPORT SERVICES (LSS) PROVIDER)
RATE SCHEDULE (Continuation Sheet)
MINORITY
STATUS
Asian American (A)
Black American (B)

BILLABLE INDIVIDUAL

(First, Middle, Last, Suffix)
Alphabetical Order

TITLE

Hispanic American (H)

GENDER

Native American Indian (N)

(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, 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, Federal Deposit Insurance Corporation, 550
17th St. NW, Washington, D.C. 20429 and to the Office of Management and Budget Paperwork Reduction Project (3064-0030), 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 5210/04A (10-05)