OMB NUMBER: 3064-0122
EXPIRATION DATE: 12/31/2019
FDIC 5210/04 (2-13)
Federal Deposit Insurance Corporation
AGREEMENT FOR SERVICES
(EXPERT/LEGAL SUPPORT SERVICES (LSS) PROVIDER)
RATE SCHEDULE
AGREEMENT FOR SERVICES
EFFECTIVE DATE (MM/DD/YYYY)
NOTE: If additional space is needed, complete and attach form FDIC 5210/04A, Agreement For Services (Expert/Legal Support Services (LSS) Provider) Rate Schedule Continuation Sheet. All
amendments to this Agreement For Services (Expert/Legal Support Services (LSS) Provider) Rate Schedule (i.e.: Name, Tax ID#, Address, Contact Person, Phone/Fax Number, Billable Individual,
Additions/Deletions) must be shown on the Agreement for Services (Expert/Legal Support Services (LSS) Amendment (form FDIC 5210/03).
SECTION I – EXPERT/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)
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/LSS Provider Authorized Representative) (Please sign) TITLE DATE SIGNED (MM/DD/YYYY)
NAME OF FDIC DELEGATED APPROVING OFFICIAL 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, Room 3082, FDIC, 550 17
th
St. NW, Washington, D.C. 20429, and to the
Office of 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.
