Form 5210/06 Legal Services Agreement (LSA) Amendment

OMB NUMBER: 3064-0122
EXPIRATION DATE: 12/31/2019
LEGAL SERVICES AGREEMENT
EFFECTIVE DATE (MM/DD/YYYY)

Federal Deposit Insurance Corporation

LEGAL SERVICES AGREEMENT (LSA)
AMENDMENT

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SECTION I – OUTSIDE COUNSEL INFORMATION
NAME OF LAW FIRM

FEDERAL TAX IDENTIFICATION NUMBER

BRANCH/OFFICE LOCATION (Each office of a multiple office firm must complete a separate E-billing Amendment form.)

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

FEDERAL TAX IDENTIFICATION NUMBER (Structural changes that result in a new Tax ID Number
may require a new Legal Services Agreement application; see E-billing Deskbook.)

ADDRESS

CITY

STATE

NAME OF CONTACT ATTORNEY

A (ADD)
OR
D (DELETE)

BILLABLE INDIVIDUAL
(First Middle Last)
Alphabetical Order by Last

TIMEKEEPER
ID

STATE
LICENSES

E-MAIL ADDRESS

TELEPHONE NUMBER (include Area Code)
(
)
MINORITY STATUS

POSITION
P (Partner)
A (Associate)
PP (Paraprofessional)
O (Other) - specify

ZIP CODE

YEARS IN
PRACTICE

A
B
H
N

(Asian American)
(Black American)
(Hispanic American)
(Native American)

GENDER
(M or F)

FAX NUMBER (include Area Code)
(
)
-

STANDARD
RATE

PERCENT
(%)
DISCOUNT

PROPOSED
FDIC
RATE

SECTION III - 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

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DATE SIGNED (MM/DD/YYYY)

SIGNATURE OF FDIC DELEGATED APPROVING OFFICIAL

LEGAL DIVISION OR OFFICE

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EFFECTIVE DATE (MM/DD/YYYY)

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PAPERWORK REDUCTION ACT NOTICE: Public reporting 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 Paperwork Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, 550 17th Street, N.W., Washington, DC
20429; and to the Office of Management and Budget, Paperwork Reduction Project (3064-0122), Washington, DC 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 5210/06(E) (6-12)