FDIC 5210/14 (5-21) Page of 

OMB Number: 3064-0122 

Expiration Date: 01/31/2023

Federal Deposit Insurance Corporation 

ORAL REPRESENTATIONS AND CERTIFICATIONS 

FOR EXPERT LEGAL SUPPORT SERVICES TELEPHONE AUTHORIZATION 

FOR EXPENDITURES UNDER $5000

PRIVACY ACT STATEMENT 

12 U.S.C. §§ 1819, 1820(a), 1822(f), and 12 C.F.R. Part 366 authorize 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 .50 hour per response, including the time for reviewing 

the 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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FDIC 5210/14 (5-21) Page of 

OMB Number: 3064-0122 

Expiration Date: 01/31/2023

Federal Deposit Insurance Corporation 

ORAL REPRESENTATIONS AND CERTIFICATIONS 

FOR EXPERT LEGAL SUPPORT SERVICES TELEPHONE AUTHORIZATION 

FOR EXPENDITURES UNDER $5000

INSTRUCTIONS: If your response is “Yes” to any of the questions in Section I or II, provide a detailed explanation in the space 

provided. 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 FDIC:

1. Have any been convicted of a felony? Yes No

Detailed Explanation

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

Detailed Explanation

3. Have any demonstrated a pattern or practice of defalcation regarding obligations? Yes No

Detailed Explanation

4. Have any caused a substantial loss ($50,000 or more) to federal deposit insurance funds? Yes No

Detailed Explanation

5. Do any have any personal, business, or financial interests or relationships which would cause a reasonable individual with 

knowledge of the relevant facts to question their integrity or impartiality? Yes No

Detailed Explanation

6. Are any an adverse party to the FDIC, RTC, FSLIC, or their successors in a lawsuit? Yes No

Detailed Explanation
FDIC 5210/14 (5-21) Page of 

OMB Number: 3064-0122 

Expiration Date: 01/31/2023

7. Have any ever been suspended, excluded, or debarred from contracting with a federal entity? Yes No

Detailed Explanation

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

Detailed Explanation

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

Detailed Explanation

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 knowledge, would answer "No" 

to the questions above? Yes No

Detailed Explanation

SECTION IV - CERTIFICATION

NOTE: The individual signing this application represents and warrants that he or 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 of Expert/LSS Provider 12. Title of Expert/LSS Provider

13. Name of Firm

14. Recorded By FDIC Official 

15. Signature 16. Date