MMS-0004 Outer Continental Shelf (OCS) Renewable Energy Lease or

30 CFR 285 - Renewable Energy and Alternate Uses of Existing Facilities on the OCS

Form 0004 - RE - LeaseGrantRelinquishment

30 CFR 285.400-437; 652a; 658c(2); - Subpart D - Lease and Grant Administration

OMB: 1010-0176

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U. S. Department of the Interior OMB Control Number: 1010-0176

Minerals Management Service OMB Approval Expires: xx/xx/xxxx


Lease Number: ___________ or Grant Number: ___________ MMS Regional Office: ____________

OUTER CONTINENTAL SHELF (OCS) RENEWABLE ENERGY
LEASE OR GRANT RELINQUISHMENT APPLICATION



The owner(s) of one hundred percent (100%) of the lease or grant interest does (do) hereby release, relinquish and forever quitclaim all of its (their) right, title and interest in and to the renewable energy lease or grant, or subdivision thereof, described in Exhibit “A” attached hereto and made a part hereof.


This relinquishment is effective on the date the Minerals Management Service approves the relinquishment application, subject to the provisions of 30 CFR 285.435. Lessee(s) or grantee(s) agree to comply fully with the decommission requirements of 30 CFR Part 285, Subpart I.


This relinquishment application may be executed in any number of counterparts, each of which is deemed an original instrument, but all of which together constitute but one and the same application, provided however, this application and any other counterpart hereof, is executed by all of the parties, and will not be approved by the Minerals Management Service unless all counterparts are filed simultaneously.


Title 18 U.S.C. 1001 makes it a crime for any person knowingly and willfully to make to any Department or agency of the United States any false, fictitious or fraudulent statements or representations as to any matter within its jurisdiction.


Insert the following information for each Lessee or Grantee


______________________ __________________________

Company Name Company Name


Company Number: __________ Company Number: ______________


By:________________________ By:__________________________

Name: Name:

Title: Title:

__________________________ __________________________

Telephone number Telephone number

__________________________ __________________________

E-mail address E-mail address

_________________________ __________________________

Fax number Fax number


___________________________ _____________________________ Execution Date Execution Date


For MMS Use only – Do Not Type Below This Line

This Relinquishment has been filed as of the date stamped on this document

and approved by the Minerals Management Service on the date below.

By__________________________________ ______________________________________________

Authorized Official for MMS Title Approval Date


Attach Notary Acknowledgement (not mandatory)


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 use in the adjudication process involved in leasing and lease operations. The MMS uses the information to track ownership of leases in the Federal OCS. Responses are mandatory (43 U.S.C. 1337).  Release of such data and information is covered under 30 CFR 285.113.  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 of this form is estimated to average 1 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, Mail Stop 5438, Minerals Management Service, 1849 C Street, NW, Washington, DC 20240.

MMS FORM MMS-0004 (mo/year) Page 1 of 3


EXHIBIT “A”


OUTER CONTINENTAL SHELF (OCS)

RENEWABLE ENERGY LEASE OR GRANT

RELINQUISHMENT




Lease Number: ____________

or

ROW Grant Number: ____________

or

RUE Grant Number: ____________


Name of Facility: _____________________________


This Relinquishment is made with respect to the following described block(s) and/or aliquot part(s) of the referenced lease or grant:



Area Name or Block Subdivision or Aliquot Part

Protraction Diagram (If entire block, enter “All”)


___________________ ________ ________________________


___________________ ________ ________________________


___________________ ________ ________________________


___________________ ________ ________________________


___________________ ________ ________________________


___________________ ________ ________________________


___________________ ________ ________________________


___________________ ________ ________________________


___________________ ________ ________________________


___________________ ________ ________________________


___________________ ________ ________________________


___________________ ________ ________________________


___________________ ________ ________________________


___________________ ________ ________________________


___________________ ________ ________________________





MMS FORM MMS-0004 (mo/year) Page 2 of 3




INSTRUCTIONS FOR

RENEWABLE ENERGY LEASE OR GRANT

RELINQUISHMENT APPLICATION


In order to relinquish a lease or grant, or an officially designated subdivision thereof, you must file one paper copy and one electronic copy of a relinquishment application with MMS.



  1. The relinquishment application must be typed.


  1. Describe the block(s) and/or officially designated subdivision(s) (in aliquot parts not less than 1/16 of the block) being relinquished, including the OCS lease number and name of facility, if any, in Exhibit “A.”.


  1. Enter names of owners (lessees or grantees) of one hundred percent (100%) of the interest in the lease or grant or officially designated subdivision being relinquished. The company number must be entered next to the name of each lessee or grantee. The name, title, and signature of your authorizing official must match exactly the name, title, and signature in MMS qualification records.


  1. Do not include or request an effective date. The relinquishment is effective on the date the relinquishment application is approved by the MMS.


  1. This form may be duplicated by means of word processing software, but any duplicate that differs from the approved form will be deemed to include any omitted language as if it were the original form.


  1. Relinquishments must be filed in duplicate (one paper copy and one electronic copy). If relinquishment of multiple leases or grants is intended in the same application, MMS must receive one paper and one electronic copy for each separate lease or officially designated subdivision being relinquished.














MMS FORM MMS-0004 (mo/year) Page 3 of 3

File Typetext/rtf
File TitleUNITED STATES
Last Modified Byblundonc
File Modified2009-09-10
File Created2009-09-10

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