OMB NUMBER: 3064-0122
EXPIRATION DATE: 12/31/2019
FD
IC 5210/06(E) (6-12)
Federal Deposit Insurance Corporation
LEGAL SERVICES AGRE
EMENT (LSA)
AMENDMENT
EFFECTIVE DATE (MM/DD/YYYY)
SECTION I – OUTSIDE COUNSEL INFORMATION
FEDERAL TAX IDENTIFICATION NUMBER
BRANCH/OFFICE LOCATION (Each office of a multiple office firm must complete a separate E-billing Amendment form.)
SECTION II – AMENDED INFORMATION (Please make appropriate changes to Firm Name, Address, Telephone/Fax Numbers, and Name of Contact Attorney.)
FEDERAL TAX IDENTIFICATION NUMBER (Structural changes that result in a new Tax ID Number
may require a new Legal Services Agreement application; see E-billing Deskbook.)
TELEPHONE NUMBER (include Area Code)
( ) -
FAX NUMBER (include Area Code)
( ) -
A (ADD)
OR
BILLABLE INDIVIDUAL
(First Middle Last)
Alphabetical Order by Last
TIMEKEEPER
STATE
YEARS IN
GENDER
STANDARD
PERCENT
(%)
PROPOSED
FDIC
A (Associate)
PP (Paraprofessional)
B (Black American)
H (Hispanic American)
SUBMITTED BY (Name and Signature of Law Firm’s Authorized Representative)
NAME OF FDIC DELEGATED APPROVING OFFICIAL (Please print legibly or type)
SIGNATURE OF FDIC DELEGATED APPROVING OFFICIAL
EFFECTIVE DATE (MM/DD/YYYY)
PAPERWORK REDUCTION ACT NOTICE: 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 17
th
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.
