0107 attach 3 Form MMS-4425

OMB Control Number 1010-0107
OMB Approval Expires August 31, 2008

U.S. Department of the Interior
Minerals Management Service
Minerals Revenue Management

Designation Form for Royalty Payment Responsibility
Form MMS-4425
SUBMIT ONE FORM PER DESIGNATION - INSTRUCTIONS ON REVERSE SIDE
(1) MMS LEASE NUMBER
(2) OMM/BLM AGENCY
ASSIGNED LEASE NUMBER
NOTE: IF THE PRODUCT CODE AND RESPONSIBILITY TYPE ARE NOT COMPLETED, MMS WILL ASSUME THE DESIGNATION COVERS ALL
(3) PRODUCT CODE
(4) RESPONSIBILITY TYPE

RENT

(5) EFFECTIVE DATE (MMDDYY)

MINIMUM ROYALTY

ROYALTY

(6) TERMINATION DATE (MMDDYY)

PLEASE PROVIDE THE FOLLOWING INFORMATION AS LESSEE:
(7) PAYOR CODE

(8) TAX IDENTIFICATION NUMBER

(9) LESSEE NAME:
LESSEE ADDRESS:

CITY, STATE, ZIP:
LESSEE EMAIL ADDRESS:
FAX:

TELEPHONE:

PLEASE PROVIDE THE FOLLOWING INFORMATION REGARDING DESIGNEE:
(10) PAYOR CODE

(11) TAX IDENTIFICATION NUMBER

(12) DESIGNEE NAME:
DESIGNEE ADDRESS:

CITY, STATE, ZIP:
DESIGNEE EMAIL ADDRESS:
FAX:

TELEPHONE:

PLEASE SIGN THE SIGNATURE LINE BELOW:

Check Box

(13) LESSEE OF RECORD

(13) OPERATING RIGHTS OWNER

(14) SIGNATURE

DATE
(Lessee of Record or Operating Rights Owner)

FORM MMS-4425 (revised 11/2004)

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INSTRUCTIONS
for Form MMS-4425
Mandatory items are in bold print.
1.

MMS Lease Number - is a 10-digit number that MMS converts from the BLM or OMM assigned lease number, i.e., BLM
lease number NM-12345 converts to MMS lease number 030-12345-0.

2.

OMM/BLM Agency Assigned Lease Number - an alpha-numeric number assigned to any contract or agreement
issued or approved by the U.S. under a mineral leasing law that authorizes exploration for, extraction of, or removal
of oil and gas.

3.

Product Code - is a 2-digit code assigned to a product description as follows:
(01) Oil

(02) Condensate

(03) Processed Gas

(04) Unprocessed Gas (07) Gas Plant Products

(25) Geothermal

(99) Other

4.

Responsibility Type - check box if you are authorizing payment for rent, minimum royalty, royalty or all of the
above.

5.

Effective Date - The effective date of the designation.

6.

Termination Date - The termination date of the designation.

Information under lessee block:
7.

Payor Code - a 5-digit code assigned to the lessee who assumes an obligation to report and remit rental or royalty due
on the lease.

8.

Tax Identification Number - a 9-digit number that is your social security number (SSN) or employer identification
number (EIN).

9.

Lessee Name, Address, Telephone, and if available, Email address and Fax Number - please print or type.

Information under designee block:
10. Payor Code - a 5-digit code assigned to the designee who assumes an obligation to report and remit rental or royalty due
on the lease.
11. Tax Identification Number - a 9-digit number that is your social security number (SSN) or employer identification number
(EIN).
12. Name, Address, Telephone Number, and if available, Email Address and Fax Number - please print or type.
13. Check the box(es) if you are lessee or record and/or operating rights owner on this lease.
14. Signature - as lessee of record or operating rights owner, and date of signing.

Paperwork Reduction Act of 1995 (PRA) Statement: The PRA (44 U.S.C. 3501 et seq.) requires us to inform you that we collect this
information to identify who is responsible for making royalty and related payments on Federal leases. The Federal Oil and Gas Royalty
Simplification and Fairness Act of 1996 (Public Law 104-185) clearly establishes the owners of operating rights and/or lease record title as
responsible for making royalty and related payments on a Federal lease. The MMS uses the information payors provide, regarding the
lessees on whose behalf they are paying, to determine if we need to inform those lessees that they must certify to MMS in writing
their respective payors as their designees. Responses are mandatory (43 U.S.C. 1334). Proprietary information is protected in accordance
with standards established by the Federal Oil and Gas Royalty Management Act of 1982 (30 U.S.C. 1733), the Freedom of Information Act [5
U.S.C. 552(b)(4)], and the Department regulations (43 CFR 2). 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. Public reporting burden for this form is
estimated to average 45 minutes per response, including the time for reviewing instructions, gathering and maintaining data, and completing
and reviewing the form. Direct comments regarding the burden estimate or any other aspect of this form to the Information Collection
Clearance Officer, Minerals Management Service, Mail Stop 4230, 1849 C Street, NW., Washington, DC 20240.

FORM MMS-4425 (revised 11/2004)

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