OMB NUMBER: 3064-0122
EXPIRATION DATE: 12/31/2019
Federal Deposit Insurance Corporation
REPRESENTATIONS AND CERTIFICATIONS
FOR EXPERTS AND LEGAL SUPPORT SERVICES PROVIDER
INSTRUCTIONS: Check one box for each question. If your response is “YES” to any of the questions in Section I or II, provide
a detailed explanation on a separate sheet of paper and attach to this form. Refer to 12 C.F.R. Part 366 for the definition of
terms.
SECTION I - DISQUALIFYING CONDITIONS/CONFLICTS OF INTEREST
Among the contractor, any management officials, or affiliated business entities of the contractor, or any employees, agents or
subcontractors of the contractor who will perform services under a proposed or existing contract with the FDIC:
1. Have any been convicted of a felony?
YES NO
2. Have any been removed from or prohibited from participating in the affairs of any insured depository
institution pursuant to any final enforcement action by the Office of the Comptroller of the Currency,
the Office of Thrift Supervision, the Board of Governors of the Federal Reserve System, the FDIC, or
their successors?
YES NO
3. Have any demonstrated a pattern or practice of defalcation regarding obligations?
YES NO
4. Have any caused a substantial loss ($50,000 or more) to federal deposit insurance funds?
YES NO
5. Do any have any personal or business, or financial interest or relationship which would cause a
reasonable individual with knowledge of the relevant facts to question their integrity or impartiality?
YES NO
6. Are any an adverse party to the FDIC, RTC, FSLIC, or their successors in a lawsuit?
YES NO
7. Have any ever been suspended, excluded, or debarred from contracting with a federal entity?
YES NO
8. Have any ever had a contract with the FDIC, RTC, FSLIC, or their successors rescinded or terminated
prior to the contract's completion involving issues of conflicts of interest or ethical responsibilities?
YES NO
SECTION II - DEFAULTS
9. Has the contractor or any company under the contractor's control defaulted on a material obligation
during the ten (10) years preceding this submission?
YES NO
SECTION III - EMPLOYEES
AGENTS
AND SUBCONTRACTORS
10. Does the contractor agree that it will prohibit any employee, agent, or subcontractor from performing
services under the contract until the contractor verifies that the employee, agent, or subcontractor,
to the best of that person's knowled
e, would answer "NO" to the questions above?
YES NO
SECTION IV - CERTIFICATION
NOTICE: The individual signing this application represents and warrants that he/she has authority to execute this application on
behalf of the contractor, certifies that all of the representations and certifications contained herein are complete and accurate,
and is aware of the penalty prescribed in 18 U.S.C. §1001 for making false statements.
11. NAME AND TITLE OF EXPERT/LSS PROVIDER (T
e or
rint) 12. NAME OF FIRM (T
e or
rint)
13. SIGNATURE 14. DATE (MM/DD/YYYY)
PRIVACY ACT STATEMENT
12 U.S.C. §§ 1819, 1820(a), 1822(f), and 12 C.F.R. Part 366 authorizes the collection of this information. The information collected will be primarily used to
review and determine the fitness and integrity of contractors providing (or seeking to provide) expert or other legal support services to the FDIC. Disclosure of this
information may be made in accordance with the "routine uses of records" listed in the FDIC’s Financial Information Management Records, # 30-64-0012, including
disclosure to: the General Accounting Office for inspection by auditors; appropriate Federal or State agencies for enforcement if a violation or possible violation of
civil or criminal law is apparent; a court, magistrate, or administrative tribunal when the FDIC is a party to the proceeding or has a significant interest in the
proceeding; the U.S. Office of Personnel Management and other appropriate agencies or offices to the extent disclosure is necessary to carry out government-wide
personnel management, investigatory, and adjudicatory functions; a congressional office in response to an inquiry made at the request of the individual; the Internal
Revenue Service, the Social Security Administration, State and local tax authorities; the FDIC Office of the Inspector General for audit purposes; a consultant, person
or entity who contracts or subcontracts with the FDIC, to the extent necessary for the performance of the contract or subcontract; and to the Department of the
Treasury, or another party for the purpose of collecting or assisting in the collection of a delinquent debt owed to the FDIC. Completing this form is voluntary.
However, failure to provide the requested information may preclude you or your company from consideration for contracting with the FDIC.
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, 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 Public Reporting Act Clearance Officer, Legal
Division, Room 3082, Federal Deposit Insurance Corporation, 550 17
th
Street, N.W., Washington, D.C. 20429, and the Office of Management and Budget,
Paperwork Reduction Project (3064-01220, 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.
FDIC 5210/09 (4-04)
