Fillable 5210-10 FDIC 5210/10(E), Outside Counsel Legal Services Agreement E-Billing Rate Schedule

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5210-10 FDIC 5210/10(E), Outside Counsel Legal Services Agreement E-Billing Rate Schedule

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OMB NUMBER: 3064-0122
EXPIRATION DATE: 12/31/2019
FDIC 5210/10-E (6-12)
Federal Deposit Insurance Corporation
OUTSIDE COUNSEL LEGAL SE
RVICES AGREEMENT (LSA)
RATE SCHEDULE
LEGAL SERVICES AGREEMENT
EFFECTIVE DATE (MM/DD/YYYY)
INSTRUCTIONS: Each office of a multiple office firm must complete a separate Outside Counsel Legal Services Agreement E-billing Rate Schedule (E-billing Rate Schedule). All amendments to this
E-billing Rate Schedule, i.e., firm’s name, Tax Identification Number, address, contact attorney, telephone/fax numbers, billable individuals, or additions/deletions, must contain the information shown on the
Legal Services Agreement E-billing Amendment form (E-billing Amendment form). Contact the Legal Financial Specialist responsible for processing your firm’s invoices, or dial 1-800-846-1901, to request
copies of the E-billing Amendment form, or download the form from the FDIC website at http://www.fdic.gov/formsdocuments/5210-06-E.doc
. NOTE: Use the mouse or tab key
to move to the next field.
Attach continuation sheets if necessary.
SECTION I – OUTSIDE COUNSEL INFORMATION
NAME OF LAW FIRM
FEDERAL TAX IDENTIFICATION NUMBER
BRANCH/OFFICE LOCATION
ADDRESS
CITY
STATE
ZIP CODE
E-MAIL ADDRESS
NAME OF CONTACT ATTORNEY
PHONE NUMBER (include Area Code) FAX NUMBER (include Area Code)
BILLABLE INDIVIDUAL
(First Middle Last)
TIMEKEEPER
ID
STATE
LICENSES
POSITION
YEARS IN
PRACTICE
MINORITY STATUS
GENDER
(M or F)
STANDARD
RATE
PERCENT
(%)
DISCOUNT
PROPOSED
FDIC
RATE
P (Partner)
A (Associate)
PP (Paraprofessional)
O (Other) - specify
A (Asian American)
B (Black American)
H (Hispanic American)
N (Native American)
SECTION II - SIGNATURES
SUBMITTED BY (Name and Signature of Law Firm’s Authorized Representative)
TITLE
DATE SIGNED (MM/DD/YYYY)
NAME OF FDIC DELEGATED APPROVING OFFICIAL (Please print legibly 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 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.
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5210-10 FDIC 521010(E), Outside Counsel Legal Services Agreement E-Billing Rate Schedule

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Completed 10 March 2020

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