Form MMS-1016 Designated Applicant Information Certification

30 CFR 253, Oil Spill Financial Responsibility for Offshore Facilities

Form 1016 exp 12-13

11a(1); 40; 41 - Form MMS-1016 - Designated Applicant Information

OMB: 1010-0106

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

Bureau of Ocean Energy Management, OMB Approval Expires: xx/xx/xxxx

Regulation and Enforcement


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 BOEMRE COMPANY NUMBER


__________________________________________________________________________________________________________ ___________________________

ADDRESS BOEMRE 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 BOEMRE 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.


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

File Typeapplication/msword
File TitleMINERALS MANAGEMENT SERVICE
AuthorAlexis London
Last Modified Byblundonc
File Modified2010-08-30
File Created2010-08-30

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