5210/06 Legal Services Agreement (LSA) Amendment

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

Federal Deposit Insurance Corporation

LEGAL SERVICES AGREEMENT (LSA) 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 5210/06 (12-20)

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

Federal Deposit Insurance Corporation

LEGAL SERVICES AGREEMENT (LSA) AMENDMENT
INSTRUCTIONS:

Legal Services Agreement Effective Date

SECTION I - OUTSIDE COUNSEL INFORMATION
1. Name of Law Firm

2. Branch/Office Location

3. Federal Tax Indentification Number

SECTION II - AMENDED INFORMATION (Please make appropriate changes to Firm Name, Address, Telephone/Fax Numbers, and Name of Contact Attorney.)
4. Name of Law Firm

5. Federal Tax Identification Number (Structural changes that result in a new Tax ID Number may require a new Legal Services Services Agreement application; see Outside Counsel Deskbook.)

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

7. Email

8. Name of Contact Attorney

9. Telephone

10. Fax Number

SECTION III - BILLING
11. Complete the following

Add or
Delete

Billable Individual
(First, Middle, Last)
Alphabetical Order

Timekeeper
ID

State
Licenses

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

Years in
Practice

Minority Status

Gender

SECTION IV - LAW FIRM'S AUTHORIZED REPRESENTATIVE
12. Name

13. Title

14. Signature

17. Title

18. Legal Division or Office

15. Date

SECTION V - FDIC DELEGATED APPROVING OFFICIAL
16. Name

19. Signature

FDIC 5210/06 (12-20)

20. Date

Standard
Rate

Percent
(%)
Discount

Proposed
FDIC Rate