SECTION III – DEFAULTS - REPRESENTATIONS
YES NO
8. Has the Contractor or any company under the Contractor’s control defaulted on a material obligation
to any insured depository institution during the ten (10) years preceding the submission of this
application? If yes, attach a description of all such instances. (See below)
SECTION IV – EMPLOYEES AND SUBCONTRACTORS - REPRESENTATIONS
9. Does the Contractor agree that it will not allow any employee, agent, or subcontractor to perform
services as a time charger under the proposed Legal Services Agreement unless the Contractor first
verifies with each such employee, agent, or subcontractor that, to the best of such person’s knowledge,
such person: (a) is not disqualified from performing services under the Legal Services Agreement
because of the existence of any of the conditions identified in Section I; (b) has no conflicts of interest
as identified in Section II, unless a request by the Contractor for a waiver or proposal for the elimination
of the conflict has been made; and (c) has not, during the ten (10) years preceding the submission of
this application, defaulted on a material obligation to any insured depository institution? (See below)
SECTION V – CERTIFICATION
NOTICE: Pursuant to 18 U.S.C. § 1001, whoever knowingly and willingly falsifies a material fact, makes a false statement,
or utilizes a false writing in connection with this application is subject to criminal sanctions under Title 18 of the United
States Code.
I represent and warrant that I have the authority to execute these certifications on behalf of the Contractor below. I further
represent and warrant that the above responses are true and correct and that all attached information is true and correct.
10. SIGNATURE (Sign in ink)
11. NAME AND TITLE (Type or Print)
12. NAME OF FIRM OR SOLE PRACTITIONER
13. DATE
DEFINITIONS
Terms used are defined in 12 C.F.R. § 366.2 as follows:
QUESTION 3. Pattern or practice of defalcation regarding obligations means two or more instances in which: (1) a loan or
advance from an insured depository institution is in default for ninety (90) or more days as to payment of principal, interest, or a
combination thereof and there remains a legal obligation to pay an amount in excess of $50,000; or (2) a loan or advance from an
insured depository institution where there has been a failure to comply with the terms to such an extent that the collateral
securing the loan or advance was foreclosed upon, resulting in a loss in excess of $50,000 to the insured depository institution.
QUESTION 4. Substantial loss to Federal deposit insurance funds means: (1) a loan or advance from an insured depository
institution, which is currently owed to the FDIC, RTC, FSLIC or their successors, or the Bank Insurance Fund (BIF), the Savings
Association Insurance Fund (SAIF), the FSLIC Resolution Fund (FRF), or funds maintained by the RTC for the benefit of insured
depositors, that is or has ever been delinquent for ninety (90) or more days as to payment of principal, interest, or a combination
thereof and on which there remains a legal obligation to pay an amount in excess of $50,000; (2) an obligation to pay an
outstanding, unsatisfied, final judgment in excess of $50,000 in favor of the FDIC, RTC, FSLIC, or their successors, or the BIF,
the SAIF, the FRF, or the funds maintained by the RTC for the benefit of insured depositors; or (3) a loan or advance from an
insured depository institution which is currently owed to the FDIC, RTC, FSLIC, or their successors, or the BIF, the SAIF, the
FRF, or the funds maintained by the RTC for the benefit of insured depositors, where there has been failure to comply with the
terms to such an extent that the collateral securing the loan or advance was foreclosed upon, resulting in a loss in excess of
$50,000.
QUESTIONS 8 & 9. Default on a material obligation means a loan or advance from an insured depository institution which has
never been delinquent for 90 or more days as to payment of principal or accrued interest, or a combination thereof, with a
remaining balance of principal and accrued interest on the ninetieth day, or any time thereafter, in an amount in excess of
$50,000.
PAPERWORK REDUCTION ACT NOTICE
Public reporting burden for this collection of information is estimated to average 75 minutes 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, Room 3082, Federal Deposit Insurance Corporation,
550 17
th
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 conducted 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 5200/01 (10-05) Page 2
