5210/03 Agreement for Services (Expert Legal Support Services(LS

OMB Number: 3064-0122
Expiration Date: 01/31/2023

Federal Deposit Insurance Corporation

AGREEMENT FOR SERVICES
(EXPERT/LEGAL SUPPORT SERVICES (LSS) PROVIDER)
AMENDMENT

PAPERWORK REDUCTION ACT

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.

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FDIC 5210/03 (5-21)

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OMB Number: 3064-0122
Expiration Date: 01/31/2023

Federal Deposit Insurance Corporation

AGREEMENT FOR SERVICES
(EXPERT/LEGAL SUPPORT SERVICES (LSS) PROVIDER)
AMENDMENT
INSTRUCTIONS: Please provide all information requested.

Agreement for Services Effective Date

SECTION I - EXPERT OR LEGAL SUPPORT SERVICES PROVIDER INFORMATION
1. Name of Expert or Legal Support Services Provider

2. Federal Tax Indentification Number

3. Branch/Office Location (Each office of a multiple office firm/business must complete a separate rate schedule.)

4. Address (Street, City, State, ZIP Code)

5. Email

6. Name of Contact Person

7. Telephone

8. Fax Number

SECTION II - BILLING
9. Complete the following

Add or
Delete

FDIC 5210/03 (5-21)

Billable Individual
(First, Middle, Last)
Alphabetical Order

Timekeeper
ID

Title

Minority Status

Gender

Hourly Rate

Fixed Rate

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OMB Number: 3064-0122
Expiration Date: 01/31/2023

Add or
Delete

Billable Individual
(First, Middle, Last)
Alphabetical Order

Timekeeper
ID

Title

Minority Status

Gender

Hourly Rate

Fixed Rate

SECTION III - EXPERT, LSS PROVIDER, OR AUTHORIZED REPRESENTATIVE
10. Name

11. Title

12. Signature

15. Title

16. Legal Division or Office

13. Date

SECTION IV - FDIC DELEGATED APPROVING OFFICIAL
14. Name

17. Signature

FDIC 5210/03 (5-21)

18. Date

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