Form BOEM-1025 Independent Designated Applicant Information Certificati

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

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

_{INDEPENDENT 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)

This form is intended for use by Designated Applicants that are not also Responsible Parties,

as defined in BOEM Regulations at 30 CFR part 553.

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

________________________________________

E-MAIL ADDRESS

2. Summary of Evidence of Oil Spill Financial Responsibility:

As an Authorized Representative of the Designated Applicant, I explicitly agree that the Designated Applicant will be jointly and severally liable for claims, under the Oil Pollution Act of 1990, as amended, 33 U.S.C. § 2701 et seq., with the Responsible Parties for the covered offshore facilities covered by this certification.

______________________________________________________________________ ___________________________________________________

NAME OF AUTHORIZED REPRESENTATIVE OF DESIGNATED APPLICANT SIGNATURE

_____________________________________________________________ _____________________________________________

TITLE OF AUTHORIZED REPRESENTATIVE OF DESIGNATED APPLICANT DATE

FORM BOEM-1025 (Month/year) PAGE 1 OF 1

Previous Editions are Obsolete.