Form MMS-4070 Form MMS-4070 Application for the Purchase of Royalty Oil

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

OMB Control Number 1010-0119
Expires February 28, 2009

APPLICATION FOR THE PURCHASE OF ROYALTY OIL
Form MMS-4070

Date of Sale: ______/_______/______

Sale No: __________________

1. Name of Refiner: ___________________________________________________________________
Address: __________________________________________________________________________
2. Number of persons employed by applicant's firm? (offshore sale only) _______________

3. Does the applicant have any affiliation with any other company(ies)?
Yes ______ No ______ (An affiliated company includes a parent or the consolidated and
unconsolidated entities (if any) which it directly or indirectly controls.) If yes, identify
the name and address of the affiliated company(ies) on an attachment to this application.
4. Provide the following data for each refinery under common control: (Attach a schedule
if additional space is required.)
Barrels of Crude Oil (in thousands)
Daily
Average monthly input *
Refinery location
refining
From own
From other
City and State
capacity
production
sources
_________________________________________

__________

___________

__________

_________________________________________

__________

___________

__________

_________________________________________

__________

___________

__________

_________________________________________

__________

___________

__________

_________________________________________

__________

___________

__________

* ATTACH A SCHEDULE DETAILING THE QUANTITY OF ALL OIL PROCESSED EACH MONTH FOR THE PAST 12 MONTHS FOR EACH
REFINERY. THIS SCHEDULE SHOULD ALSO IDENTIFY WHETHER THE OIL WAS OBTAINED FROM PRODUCERS UNDER APPLICATION'S
DIRECT OR INDIRECT CONTROL (OWN PRODUCTION) OR BY PURCHASE FROM OTHER SOURCES. OTHER SOURCES SHOULD BE IDENTIFIED
(SPOT MARKET, GOVERNMENT ROYALTY OIL, 20% SET ASIDE, NAVAL PETROLEUM RESERVE PROGRAM, ETC.). OIL RECEIVED IN
EXCHANGE FOR THE APPLICANT'S OWN PRODUCTION AND INPUT INTO THE APPLICANT'S REFINERY(IES) WILL BE CONSIDERED TO BE THE
APPLICANT'S OWN PRODUCTION FOR PURPOSES OF DETERMINING ELIGIBILITY AND MUST BE IDENTIFIED AS SUCH AS THIS APPLICATION.

5. If receiving royalty oil under a current Government royalty oil contract(s), identify contract
number(s) ________________________________________________________________________
6. Does the applicant want to be considered preference eligible for this sale? Yes _______ No _______
Note: Refiners who are granted preference eligibility in this sale will not be granted preference eligibility
in subsequent sales held for other regions prior to the date stated in the Federal Register Notice applicable to this
sale.
If yes, specify the area of preference eligibility that the applicant is interested in as defined in the Federal
Register Notice applicable to this sale:
_______ Gulf of Mexico
_______ North Central Onshore
_______ Pacific Offshore
_______ Western Onshore

Form MMS-4070 (Rev. 08/2008)

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

OMB Control Number 1010-0119
Expires February 28, 2009

APPLICATION FOR THE PURCHASE OF ROYALTY OIL
Form MMS-4070

If yes, this preference eligibility request is supported by:
_______ Location of refinery operations
_______ Attached documentation, as defined in the Federal Register Notice applicable to this sale, proving that
the applicant established a history of purchasing crude oil produced from the preference area during the past 12
months that the applicant either refined or exchanged for oil that the applicant refined.
7. Identify the sale region where the applicant proposes to purchase royalty oil and the volume of oil requested.
Also provide the name and location of refinery(ies) to be used by applicant for royalty oil: (Attach schedule if
additional space is required.)
Quantity requested
(barrels per day
in thousands)

Name of refinery to
be used by applicant
for royalty oil

Location of refinery to
be used by applicant
for royalty oil

_______________________

_________________

__________________

__________________

_______________________

_________________

__________________

__________________

_______________________

_________________

__________________

__________________

Sale Region

CERTIFICATION: The applicant certifies that it is an "eligible refiner" for the purchase of Government royalty oil,
as defined in the regulations.
WARNING: This is to inform you that failure to report accurately and timely in accordance with the statutes,
regulations, or terms of the lease, permit, or contract may result in late payment charges, civil penalties, or liquidated
damages being assessed without further notification. Intentional false or inaccurate reporting is subject to criminal
prosecution in accordance with applicable Federal law(s).

I have read and examined the statements in this report and agree they are accurate and complete:
Name (typed or printed) and authorized signature
Date

Name of preparer

Telephone

Paperwork Reduction Act of 1995 (PRA) Statement: The PRA (44 U.S.C. 3501 et seq.) requires us to inform you that collecting this
information allows the Secretary to dispose of oil taken as royalty by conducting a sale or by allocating it to eligible refiners. The MMS uses the
information to determine if the applicant meets eligibility requirements to contract to purchase royalty oil. Responses are required to obtain a benefit
(30 CFR 208.6), i.e., to participate in royalty oil sales. 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 1.25 hour
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 5438, 1849 C Street, NW, Washington, DC 20240.

Form MMS-4070 (Rev. 08/2008)

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