5210/02 Legal Support Services (LSS) Provider Invoice for Fees a

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OMB NUMBER: 3064-0122
EXPIRATION DATE: 07/31/2013

Federal Deposit Insurance Corporation

LEGAL SUPPORT SERVICES (LSS) PROVIDER
INVOICE FOR FEES AND EXPENSES (IF&E)
MATTER NUMBER

MATTER CAPTION

SECTION I – FIRM AND INSTITUTION INFORMATION
INSTITUTION NUMBER

FEDERAL TAX ID NUMBER

FINANCIAL INSTITUTION NAME
CITY

STATE

LSS PROVIDER NAME

ADDRESS

CITY

STATE

ZIP CODE

LSS FIRM PROVIDER CONTACT

TELEPHONE NUMBER

LSS FIRM PROVIDER ACCOUNTS RECEIVABLE CONTACT

TELEPHONE NUMBER

FDIC OFFICE LOCATION

TELEPHONE NUMBER

FDIC ATTORNEY

SECTION II – CURRENT BILLING INFORMATION
INVOICE NUMBER

BILLING PERIOD DATE (MM/DD/YYYY)
FROM:

ACTION

THROUGH:
FEES BILLED

EXPENSES BILLED

Court Reporting Services

$

$

Appraisal Services

$

$

Copy/Imaging Services

$

$

Escrow Services

$

$

Registered Agent Services

$

$

Title Company Services

$

$

Other Services (Specify)

$

$

SUBTOTAL: Fees Invoiced

$

SUBTOTAL: Expenses Invoiced

$

INVOICE GRAND TOTAL

$

SECTION III – CERTIFICATION
I certify that the information contained herein is true and correct to the best of my knowledge and belief, and that all charges for legal
services and disbursements reflected herein are in accordance with our retention agreement with the FDIC Legal Division.

NAME AND TITLE OF LSS PROVIDER (Print or type)

AUTHORIZED SIGNATURE

DATE

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 Public Reporting Act Clearance Officer, Legal Division, Federal Deposit
Insurance Corporation, 550 17th Street, N.W., Washington, DC 20429, and the Office and 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.
FDIC 5210/02 (4-06)

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