5210/06 Legal Services Agreement (LSA) Amendment

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

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Federal Deposit Insurance Corporation

LEGAL SERVICES AGREEMENT (LSA)
AMENDMENT

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SECTION I – LEGAL SERVICES PROVIDER INFORMATION
NAME OF LAW FIRM

FEDERAL TAX IDENTIFICATION NUMBER

BRANCH/OFFICE LOCATION (Each office of a multiple office firm/business must complete a separate rate amendment.)

SECTION II – AMENDED INFORMATION (Please make appropriate changes to Firm Name, Address, Telephone Number, Fax Number, and Contact Attorney.)
NAME OF LAW FIRM

FEDERAL TAX IDENTIFICATION NUMBER (Structural changes that result in a new tax ID
number may require a new application and a new LSA, see Outside Counsel Deskbook.)

ADDRESS

CITY

NAME OF CONTACT ATTORNEY

STATE

ZIP CODE

NEW TELEPHONE NUMBER (Include Area Code)

E-MAIL ADDRESS
FAX NUMBER (Include Area Code)

MINORITY
STATUS
BILLABLE INDIVIDUAL
ADD (A)
OR
DELETE (D)

(First, Middle, Last,
Suffix)
Alphabetical Order

STATE
LICENSES

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

YEARS
IN
PRACTICE

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

GENDER
(M or F)

STANDARD
RATE

PERCENT
%
DISCOUNT

PROPOSED
FDIC
RATE

SECTION III – SIGNATURES
SUBMITTED BY (Name and Signature of Firm’s Authorized Representative)

TITLE

DATE SIGNED (MM/DD/YYYY)

FDIC DELEGATED APPROVING OFFICIAL (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 the Paper Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, 550 17th
Street, N.W., Washington, DC 20429, and the Office of Management and Budget, Paperwork Reduction Project (3064-0122), Washington, D.C. 20503. Any 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 5210/06 (10-05)