Form 5210/10 Outside Counsel Legal Services Agreement Rate Schedule

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

Federal Deposit Insurance Corporation

OUTSIDE COUNSEL LEGAL SERVICES AGREEMENT (LSA)
RATE SCHEDULE

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 5210/10 (5-21)

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

Federal Deposit Insurance Corporation

OUTSIDE COUNSEL LEGAL SERVICES AGREEMENT (LSA)
RATE SCHEDULE
INSTRUCTIONS: All Amendments to this Rate Schedule, i.e., firm's name, Tax Identification Number, address, contact attorney, telephone/fax numbers, billable individuals, or additions/
deletions, must contain the information shown on the Legal Services Agreement (Amendment form).

Legal Services Agreement Effective Date

Download the Amendment form from the FDIC website at www.fdic.gov/formsdocuments/f5210-06.pdf.
SECTION I - OUTSIDE COUNSEL INFORMATION
1. Name of Law Firm

2. Branch/Office Location

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

5. Email

6. Name of Contact Attorney

7. Telephone

3. Federal Tax Identification Number

8. Fax Number

SECTION II - BILLING
9. Complete the following

Billable Individual
(First, Middle, Last)
Alphabetical Order

FDIC 5210/10 (5-21)

Timekeeper
ID

State
Licenses

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

Years in
Practice

Minority Status

Gender

Standard Rate

Percent
(%)
Discount

Proposed
FDIC Rate

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

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

Standard Rate

Percent
(%)
Discount

Proposed
FDIC Rate

SECTION III - LAW FIRM'S 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 5210/10 (5-21)

18. Date

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