OMB NUMBER: 3064-0122
EXPIRATION DATE: 12/31/2019
Federal Deposit Insurance Corporation
LEGAL SUPPORT SERVICES (LSS) PROVIDER
INVOICE FOR FEES AND EXPENSES (IF&E)
MATTER NUMBER MATTER CAPTION
SECTION I – FIRM AND INSTITUTION INFORMATION
INSTITUTION NUMBER FINANCIAL INSTITUTION NAME
CITY STATE
FEDERAL TAX ID NUMBER LSS PROVIDER NAME ADDRESS
CITY STATE ZIP CODE
LSS FIRM PROVIDER CONTACT TELEPHONE NUMBER
LSS FIRM PROVIDER 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:
ACTION FEES BILLED EXPENSES BILLED
Court Reporting Services $ $
Appraisal Services $ $
Copy/Imaging Services $ $
Escrow Services $ $
Registered Agent Services $ $
Title Company Services $ $
Other Services (Specify) $ $
SUBTOTAL: Fees Invoiced
$
SUBTOTAL: Expenses Invoiced
$
INVOICE 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 LSS PROVIDER (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 and 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 5210/02 (4-06)
