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

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

Federal Deposit Insurance Corporation

AGREEMENT FOR SERVICES
(EXPERT/LEGAL SUPPORT SERVICES (LSS) PROVIDER)
RATE SCHEDULE (Continuation Sheet)

BILLABLE INDIVIDUAL

(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, 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 (2-13)

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