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

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OMB NUMBER: 3064-0122
EXPIRATION DATE: 07/31/2013

Federal Deposit Insurance Corporation

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

BILLABLE INDIVIDUAL
ADD (A)
or
DELETE (D)

(First, Middle, Last, Suffix)
Alphabetical Order

TIMEKEEPER ID

TITLE

MINORITY
STATUS
Asian American (A)
Black American (B)
Hispanic American (H)
Native American Indian (N)

Page

GENDER
(M or F)

of

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
th
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 17 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 (2-13)

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