OMB NUMBER: 3064-0122
EXPIRATION DATE: 12/31/2019
Federal Deposit Insurance Corporation
EXPERT INVOICE FOR FEES AND EXPENSES (EIF&E)
MATTER NUMBER MATTER CAPTION
SECTION I – FIRM AND INSTITUTION INFORMATION
INSTITUTION NUMBER FINANCIAL INSTITUTION NAME
CITY STATE
EXPERT FIRM NAME ADDRESS FEDERAL TAX ID NUMBER
CITY STATE ZIP CODE
EXPERT FIRM CONTACT TELEPHONE NUMBER
EXPERT FIRM ACCOUNTS RECEIVABLE CONTACT TELEPHONE NUMBER
FDIC OFFICE LOCATION FDIC ATTORNEY TELEPHONE NUMBER
SECTION II – CURRENT BILLING INFORMATION
INVOICE NUMBER BILLING PERIOD DATE (MM/DD/YYYY)
FROM: THROUGH:
FEES BILLED 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 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 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)
