Form 5210/11 Legal Invoice for Fees and Expenses

Refresh
OMB NUMBER: 3064-0122
EXPIRATION DATE: 12/31/2019

Federal Deposit Insurance Corporation

LEGAL INVOICE FOR FEES AND EXPENSES
SECTION I – LAW FIRM AND INSTITUTION INFORMATION
Matter Number

Matter Caption

Institution Number

Name of Institution

City

Federal Tax Number

State

ZIP Code

State

ZIP Code

Firm's Name
Address

Vendor Number

City

Law Firm Contact Attorney

Telephone Number (Include Area Code)

Law Firm Accounts Receivable Contact

Telephone Number (Include Area Code)

FDIC Office Location

SECTION II

–

Telephone Number (Include Area Code)

FDIC Attorney

CURRENT BILLING INFORMATION

Invoice Number:

Billing Period Date (MM/DD/YYYY) From:

FEES BILLED

EXPENSES BILLED

./

./

. Through:

./

./

.

GRAND TOTAL

SECTION III – CERTIFICATION
I certify that the information contained herein is true and correct to the best of my knowledge, information, and belief, and that all charges
for legal services and disbursements reflected herein are in accordance with our Legal Services Agreement with the Legal Division and the
Division's Outside Counsel Deskbook.
Name of Authorized Law Firm Representative (Print legibly or type)

Title of Authorized Law Firm Representative

Signature of Authorized Law Firm Representative

Date

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 Street,
N.W., Washington, D.C. 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.
FDIC 5210/11 (10-05)