Form 1016 Designated Applicant Information Certification

U.S. Department of the Interior OMB Control Number 1010-0106

Minerals Management Service OMB Approval Expires xx/xx/xxxx

DESIGNATED APPLICANT INFORMATION CERTIFICATION

OIL POLLUTION ACT OF 1990 APPLICATION FOR CERTIFICATION OF OIL SPILL FINANCIALRESPONSIBILITY

(TYPE OR PRINT ALL INFORMATION EXCEPT SIGNATURES)

1. DESIGNATED APPLICANT: ______________________________________________________ ___________________________

COMPANY LEGAL NAME MMS COMPANY NUMBER

__________________________________________________________________________________________________________ ___________________________

ADDRESS MMS COMPANY REGION

___________________________________________________________________________________________________________________________________________

CITY STATE ZIP CODE

_____________________________________________________________________________________________________ ( )___________________________

CONTACT PERSON AREA CODE and TELEPHONE NUMBER

_____________________________________________________________________________________________________ ( )___________________________

CONTACT PERSON’S TITLE AREA CODE and FAX NUMBER

__________________________

E-MAIL ADDRESS

2. SUMMARY OF EVIDENCE OF OIL SPILL FINANCIAL RESPONSIBILITY:

Type of Evidence		Amount (in U.S. Dollars)		Effective Date of Evidence		Expiration Date of Evidence
■ Self-Insurance (MMS-1018)		$
■ Indemnity (MMS-1018)		$
■ Surety Bonds (MMS-1020)		$
■ Insurance (MMS-1019)		$
■ Other:		$
TOTAL AMOUNT		$

3. AS AN OFFICER OR DESIGNATED AGENT OF THE DESIGNATED APPLICANT, I CERTIFY THE INFORMATION CONTAINED HEREIN, INCLUDING ALL INFORMATION IN THE ATTACHED FORMS, IS TRUE AND CORRECT TO

THE BEST OF MY KNOWLEDGE. THE DESIGNATED APPLICANT AGREES TO ESTABLISH AND MAINTAIN OIL SPILL FINANCIAL RESPONSIBILITY ON BEHALF OF ALL THE PARTIES RESPONSIBLE FOR THE LEASES, PERMITS, RIGHTS OF USE AND EASEMENT, AND PIPELINE SEGMENTS COVERED BY THIS APPLICATION. THE DESIGNATED APPLICANT AGREES TO BE LIABLE FOR CLAIMS UNDER THE OIL POLLUTION ACT OF 1990 JOINTLY AND SEVERALLY WITH ALL THE PARTIES RESPONSIBLE FOR THE LEASES, PERMITS, RIGHTS OF USE AND EASEMENT, AND PIPELINE SEGMENTS COVERED BY THIS APPLICATION. THE DESIGNATED APPLICANT WILL IMMEDIATELY NOTIFY THE OIL SPILL FINANCIAL RESPONSIBILITY PROGRAM OF ANY CHANGES IN THE INFORMATION INCLUDED IN THIS APPLICATION.

___________________________________________________________________ ___________________________

NAME SIGNATURE

________________________________________________________________________________________________ _______________________________________

TITLE DATE

4. THE DESIGNATED APPLICANT’S U.S. AGENT FOR SERVICE OF PROCESS IS: ___________________________

NAME

__________________________________________________________________________________________________________ _____________________

ADDRESS MMS COMPANY NUMBER

____________________________________________________________________________________________________________________________________________

CITY STATE ZIP CODE

( )___________________________ ( )___________________________ ____________________________

AREA CODE and TELEPHONE NUMBER AREA CODE and FAX NUMBER E-MAIL ADDRESS

If the designated U.S. Agent for Service of Process cannot be served due to death, disability, or unavailability, the Director, U.S. Coast Guard National Pollution Funds Center, is the U.S. Agent for Service of Process.

MMS FORM MMS-1016 (Mo/Year - Supersedes all previous versions of form MMS-1016 which may not be used). Page 1 of 1