5210/01 Representations and Certifications for Legal Contractors

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OMB NUMBER: 3064-0122
EXPIRATION DATE: 07/31/2013

Federal Deposit Insurance Corporation

EXPERT INVOICE FOR FEES AND EXPENSES (EIF&E)
MATTER NUMBER

MATTER CAPTION

SECTION I – FIRM AND INSTITUTION INFORMATION
INSTITUTION NUMBER

FEDERAL TAX ID NUMBER

FINANCIAL INSTITUTION NAME
CITY

STATE

EXPERT FIRM NAME

ADDRESS

CITY

STATE

ZIP CODE

EXPERT FIRM CONTACT

TELEPHONE NUMBER

EXPERT FIRM ACCOUNTS RECEIVABLE CONTACT

TELEPHONE NUMBER

FDIC OFFICE LOCATION

TELEPHONE NUMBER

FDIC ATTORNEY

SECTION II – CURRENT BILLING INFORMATION
INVOICE NUMBER

BILLING PERIOD DATE (MM/DD/YYYY)
FROM:

FEES BILLED

THROUGH:

EXPENSES BILLED

GRAND TOTAL

SECTION III – CERTIFICATION
I certify that the information contained herein is true and correct to the best of my knowledge and belief, and that all charges for legal
services and disbursements reflected herein are in accordance with our retention agreement with the FDIC Legal Division.

NAME AND TITLE OF EXPERT (Print or type)

AUTHORIZED SIGNATURE

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, 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 the
Public Reporting Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, 550 17th Street, N.W.,
Washington, DC 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 number.
FDIC 5210/01 (4-06)