Form BOEM-1021 Covered Offshore Facilities

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

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

_{COVERED OFFSHORE FACILITIES}

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

2. The following list comprises all of the locations of covered offshore facilities to be covered

NUMBER

_{by my certification of oil spill financial responsibility.}

NAME OF AUTHORIZED REPRESENTATIVE SIGNATURE OF AUTHORIZED REPRESENTATIVE

TITLE DATE

_{3. Locations of covered offshore facilities:}

STATE OR OCS REGION	LEASE NUMBER	ALIQUOT PORTION (If Applicable)	AREA NAME	BLOCK NUMBER	PERMIT NUMBER	RUE or ROW NUMBER	PIPELINE SEGMENT NUMBER	POTENTIAL WORST CASE OIL- SPILL DISCHARGE (In Barrels)

FORM BOEM-1021 (Month/Year) PAGE 1 OF 2

Previous Editions are Obsolete.

_{3. Locations of covered offshore facilities (continued):}

STATE OR OCS REGION	LEASE NUMBER	ALIQUOT PORTION (If Applicable)	AREA NAME	BLOCK NUMBER	PERMIT NUMBER	RUE or ROW NUMBER	PIPELINE SEGMENT NUMBER	POTENTIAL WORST CASE OIL- SPILL DISCHARGE (In Barrels)

If additional space is required, additional copies of this page may be attached as continuation pages.

FORM BOEM-1021 (Month/Year) PAGE 2 OF 2

Previous Editions are Obsolete.