OMB NUMBER: 3066-0122
EXPIRATION DATE: 12/31/2019
Federal Deposit Insurance Corporation
LEGAL SUPPORT SERVICES (LSS) PROVIDER BUDGET FORM
Matter Number Matter Caption
Institution Number LSS Firm/Provider Name
Bank Thrift
PART I - BUDGET INFORMATION
Fees Estimated Recovery Value (if
Hourly Rate (Rate Schedule
must be attached)
Fixed Fee
$
Contingent Fee
( % of $ )
$
Specify Nature of Work to be Performed (Attach additional sheet(s) as necessary.)
1.
2.
3.
4.
ACTION FEES EXPENSES TOTAL
Court Services Reporting Services
Appraisal
Copy/Imaging Services
Escrow Services
Registered Agent Services
Title Company Services
Other Services (Specify):
Estimated Hours For Completion:
Estimated Completion Date (MM/DD/YY):
GRAND TOTAL OF BUDGET
PART II - LSS FIRM/PROVIDER BUDGET ACKNOWLEDGMENT
I acknowledge that the budget information contained herein is correct to the best of my knowledge and written approval of
the FDIC Legal Division is required for any increase in the total budget amount.
Authorized LSS Firm/Provider Signature Date
Print/Type Name and Title of Authorized LSS
Telephone Number (Include Area Code) FAX Number (Include Area Code)
PART III - BUDGET AUTHORIZATION FOR LSS FIRM/PROVIDER TO PROCEED
Signature of FDIC Attorney (Recommending Approval of Budget) Date
Signature of FDIC Delegated Authority Date Budget Approved
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, D.C. 20429, and the Office of Management and Budget, Paperwork Reduction Project (3064-0122), Washington, D.C
.
20503. Any 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 5210/15 (10-05)
