Form BOEM-1016 Designated Applicant Information Certificaton

U.S. Department of the Interior OMB Control No.: _xxxxxxx

_{Bureau of Ocean Energy Management Expiration Date: xxxxxxx}

_{DESIGNATED APPLICANT INFORMATION CERTIFICATION}

CERTIFICATION OF OIL SPILL FINANCIAL RESPONSIBILITY

IN ACCORDANCE WITH THE REQUIREMENTS OF THE OIL POLLUTION ACT OF 1990

(TYPE OR PRINT ALL INFORMATION EXCEPT SIGNATURES)

1. Designated Applicant:

COMPANY LEGAL NAME BOEM COMPANY NUMBER

ADDRESS BOEM COMPANY REGION

CITY STATE ZIP CODE

( ) CONTACT PERSON AREA CODE and TELEPHONE NUMBER

( ) CONTACT PERSON’S TITLE AREA CODE and FAX NUMBER

_{2. Summary of Evidence of Oil Spill Financial Responsibility:}

E-MAIL ADDRESS

Type of Evidence Amount (in U.S. Dollars) Effective Date of Evidence Expiration Date of Evidence

■ Self-Insurance (BOEM-1018) $

■ Financial Guarantee (BOEM-1023) $

■ Surety Bonds (BOEM-1020) $

■ Insurance (BOEM-1019) $

■ Other $

_{TOTAL AMOUNT $}

3. The Designated Applicant, for all of the Responsible Parties whose Designated Applicant authorizations (form BOEM-1017) are on file or attached, agrees to establish and maintain oil spill financial responsibility (OSFR), under the Oil Pollution Act of 1990, as amended, 33 U.S.C. § 2701 et seq., for all said Responsible Parties. This OSFR will be maintained continuously for those leases, permits, rights of use and easement, and pipeline segments identified in form(s) BOEM-1017 on file or attached. I will immediately notify the Responsible Parties of any claims that I receive. I will immediately notify the BOEM OSFR program if information on this form changes. I certify the information contained herein, including all the information on the attached forms, is complete, true, and correct to the best of my information and knowledge.

NAME OF AUTHORIZED REPRESENTATIVE SIGNATURE

TITLE OF AUTHORIZED REPRESENTATIVE DATE

4. The Designated Applicant’s U.S. Agent for Service of Process is:

NAME

ADDRESS BOEM COMPANY NUMBER

CITY STATE ZIP CODE

( )

( )

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

FORM BOEM-1016 (Month/year) PAGE 1 OF 1

Previous Editions are Obsolete.