5210/11 Legal Invoice for Fees and Expenses

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

Federal Deposit Insurance Corporation

LEGAL INVOICE FOR FEES AND EXPENSES
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.
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FDIC 5210/11 (5-21)

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

Federal Deposit Insurance Corporation

LEGAL INVOICE FOR FEES AND EXPENSES
INSTRUCTIONS: Please provide all information requested.
SECTION I - INSTITUTION INFORMATION
1. Matter Number

2. Matter Caption

3. Name of Institution

4. Institution Number

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

SECTION II - LAW FIRM INFORMATION
6. Firm's Name

7. Federal Tax Number

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

9. Vendor Number

10. Law Firm Contact Attorney

11. Telephone

12. Law Firms Accounts Receivable Contact

13. Telephone

14. FDIC Office Location

15. FDIC Attorney

16. Telephone

SECTION III - CURRENT BILLING INFORMATION
17. Invoice Number

18. Billing Period Date
From:

To:

19. Complete the following.
Fees Billed

Expenses Billed

Total

Grand Total
SECTION IV - AUTHORIZED LAW FIRM REPRESENTATIVE 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.
20. Name

22. Signature
FDIC 5210/11 (5-21)

21. Title

23. Date
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