OMB NUMBER: 3064-0122
EXPIRATION DATE: 12/31/2019
Federal Deposit Insurance Corporation
AGREEMENT FOR SERVICES
(EXPERT/LEGAL SUPPORT SERVICES (LSS) PROVIDER)
AMENDMENT
AGREEMENT FOR SERVICES
EFFECTIVE DATE (MM/DD/YYYY)
SECTION I – EXPERT OR LEGAL SUPPORT SERVICES PROVIDER INFORMATION
NAME OF EXPERT OR LEGAL SUPPORT SERVICES PROVIDER FEDERAL TAX IDENTIFICATION NUMBER
BRANCH/OFFICE LOCATION (Each office of a multiple office firm/business must complete a separate rate schedule.)
ADDRESS CITY STATE ZIP CODE E-MAIL ADDRESS
NAME OF CONTACT PERSON PHONE NUMBER (Include Area Code) FAX NUMBER (Include Area Code)
ADD (A)
or
DELETE (D)
BILLABLE INDIVIDUAL
(First, Middle, Last,
Suffix)
Alphabetical Order
TIMEKEEPER ID TITLE
MINORITY
STATUS
Asian American (A)
Black American (B)
Hispanic American (H)
Native American Indian (N)
GENDER
(M or F)
HOURLY
RATE
FIXED
RATE
SECTION II – SIGNATURES
SUBMITTED BY (Name and Signature of Expert or LSS Provider or Authorized Representative) TITLE DATE SIGNED (MM/DD/YYYY)
FDIC DELEGATED APPROVING OFFICIAL (Please print or type) TITLE DATE SIGNED (MM/DD/YYYY)
SIGNATURE OF FDIC DELEGATED APPROVING OFFICIAL LEGAL DIVISION OR OFFICE EFFECTIVE DATE (MM/DD/YYYY)
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 Paper Reduction 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). 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 5210/03 (2-13)
