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

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OMB NUMBER: 3064-0122
EXPIRATION DATE: 07/31/2013
AGREEMENT FOR SERVICES
EFFECTIVE DATE (MM/DD/YYYY)

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
BILLABLE INDIVIDUAL

Asian American (A)

(First, Middle, Last,
Suffix)

Black American (B)

ADD (A)
or
DELETE (D)

Alphabetical Order

Hispanic American (H)
TIMEKEEPER ID

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 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
th
collection of information, including suggestions for reducing this burden to the Paper Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, 550 17 Street N.W., Washington,
DC 20429, and the Office of Management and Budget, Paperwork Reduction Project (3064-0122). 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 5210/03 (2-13)

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