Representations and Certifications for Experts and Legal Support Services Provider

• Legal Form Number: FDIC Form 5210/09
• Section: Federal Deposit Insurance Corporation

Page of FDIC 5210/09 (5-21)

OMB Number: 3064-0122

Expiration Date: 01/31/2023

Federal Deposit Insurance Corporation

REPRESENTATIONS AND CERTIFICATIONS

FOR EXPERTS AND LEGAL SUPPORT SERVICES PROVIDER

PRIVACY ACT STATEMENT

The FDIC is authorized to request this information from you by 12 U.S.C §§ 1819, 1820, 1822(f); Executive Order 9397 as amended;

and 12 C.F.R. Part 366. The information collected will be primarily used to determine whether you meet the required fitness and

integrity standards to provide expert or other legal support services to the FDIC. 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 you to provide expert

or other legal support services to the FDIC. 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, 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 17th 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.

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