Law Firm Travel Voucher

• Legal Form Number: FDIC Form 5210/12
• Section: Federal Deposit Insurance Corporation

Page of FDIC 5210/12 (5-21)

OMB Number: 3064-0122

Expiration Date: 01/31/2023

Federal Deposit Insurance Corporation

FIRM TRAVEL VOUCHER

PRIVACY ACT STATEMENT

The FDIC is authorized to request this information from you by 12 U.S.C § 1819, and Executive Order 9397 as amended. The

information collected will be primarily used to process your request for travel expense reimbursement. Furnishing the requested

information is voluntary, but failure to provide the requested information in whole or in part may delay or prohibit any further

consideration of your request for travel expense reimbursement. The information you provide may be provided to appropriate Federal,

state, local or foreign agencies and law enforcement authorities; to a court, administrative tribunal, or a party in litigation; and to

contractors, agents and other third parties as authorized by law and in accordance with any of the other routine uses described in the

FDIC Financial Information Management Records (FDIC 30-64-0012) System of Records available at www.fdic.gov/about/privacy/. If

you have questions or concerns about the collection or use of the information, you may contact the FDIC's Chief Privacy Officer at

Privacy@fdic.gov.

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 17th Street, N.W., Washington, DC 20429, and 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.

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