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pdfOMB 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.
Page down to access form 5210/03
FDIC 5210/03 (5-21)
Page of
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
Page of
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
Page of
| File Type | application/pdf |
| File Title | 5210/03, Agreement for Services (Expert/Legal Support Services (LSS) Provider) Amendment |
| Subject | For questions regarding this form, email [email protected]. |
| Author | Andrea Hill |
| File Modified | 2021-05-12 |
| File Created | 2021-05-12 |