5210/10 Outside Counsel Legal Services Agreement Rate Schedule

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OMB NUMBER: 3064-0122
EXPIRATIONDATE:: 07/31/2013

LEGAL SERVICES AGREEMENT
EFFECTIVE DATE (MM/DD/YYYY)

Federal Deposit Insurance Corporation

OUTSIDE COUNSEL LEGAL SERVICES AGREEMENT
RATE SCHEDULE

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INSTRUCTIONS: Each office of a multiple office firm must complete a separate Outside Counsel Legal Services Rate Schedule. All amendments to this Legal Services Agreement Rate Schedule,
i.e., firm's name, Tax Identification Number, address, contract attorney, telephone/fax numbers, billable individual, or additions/deletions must contain the information shown on the Legal Services
Agreement Amendment form. Contact the Legal Information Specialist processing your firm's invoice or dial 1 (800) 846-1901 to request copies of the Legal Services Agreement Amendment form
or download it from the FDIC Internet at (http://www.fdic.gov/buying/legal/outside/APPNDX/D_3.pdf ). NOTE: Use the mouse to move to the next field. Attach continuation sheets if necessary.

SECTION I – OUTSIDE COUNSEL INFORMATION
NAME OF LAW FIRM

FEDERAL TAX IDENTIFICATION NUMBER

BRANCH/OFFICE LOCATION
ADDRESS

CITY

STATE

NAME OF CONTACT ATTORNEY

PHONE NUMBER (Include Area Code)
POSITION

BILLABLE INDIVIDUAL
(First, Middle, Last)
Alphabetical Order

ZIP CODE

STATE
LICENSES

Partner (P)
Associate (A)
Paraprofessional (PP)
Specify Other Position (O)

YEARS
IN
PRACTICE

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

GENDER
(M OR F)

E-MAIL ADDRESS
FAX NUMBER (Include Area Code)

STANDARD
RATE

PERCENT
%
DISCOUNT

PROPOSED
FDIC
RATE

SECTION II – SIGNATURES
SUBMITTED BY (Name and Signature of Law Firm's Authorized Representative)

TITLE

DATE SIGNED (MM/DD/YYYY)

NAME OF FDIC DELEGATED APPROVING OFFICIAL (Please print legibly 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 collection of information, including suggestions for reducing this burden, to Paper Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, 550 17th
Street, N.W., Room MB-3082, Washington, D.C. 20429; and to 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 5210/10 (10-05)