Form BOEM-1021 Covered Offshore Facilities

U.S. Department of the Interior OMB Control No.: _1010-0106

_{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 3

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 3

Previous Editions are Obsolete.

U.S. Department of the Interior OMB Control No.: 1010-0106

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

_{PAPERWORK REDUCTION ACT STATEMENT}

BUREAU OF OCEAN ENERGY MANAGEMENT

OIL POLLUTION ACT OF 1990

OIL SPILL FINANCIAL RESPONSIBILITY FOR OFFSHORE FACILITIES

The Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.) requires us to inform you that the Bureau of

Ocean Energy Management (BOEM) collects this information to:

1. Provide a standard method for establishing eligibility for oil spill financial responsibility (OSFR) for offshore facilities;

2. Identify and maintain a record of those offshore facilities that have a potential oil spill liability;

3. Establish and maintain a continuous record, over the liability term specified in Title I of the Oil Pollution Act of 1990, of financial evidence and instruments established to pay claims for oil spill cleanup and damages resulting from operations conducted on offshore facilities and the transportation of oil from offshore platforms and wells;

4. Establish and maintain a continuous record of Responsible Parties, as defined in Title I of the Oil

Pollution Act of 1990, and their agents or Authorized Representatives for oil spill financial responsibility for offshore facilities; and

5. Establish and maintain a continuous record, over the liability term specified in Title I of the Oil Pollution Act of 1990, of persons to contact and U.S. Agents for Service of Process for claims associated with oil spills from offshore facilities.

The BOEM will routinely use the information to:

1. Ensure compliance of offshore lessees and owners and operators of offshore facilities with Title I of the Oil Pollution Act of 1990;

2 Establish eligibility of applicants for OSFR; and

3. Establish a reference source of names, addresses, and telephone numbers of Responsible Parties for offshore facilities and their Authorized Representatives and Guarantors for claims associated with oil pollution from designated offshore facilities.

Responses are mandatory (33 U.S.C. 2716). No confidential or proprietary information is required to be submitted. The BOEM considers oil spill financial responsibility demonstrations, including supporting audited financial statements, to be public information open for review under the Freedom of Information Act (5 U.S.C. 552).

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 Office of Management and Budget (OMB) Control Number. The public reporting burden for an application for certification of oil spill financial responsibility is listed below. The burden includes the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the application. The average burden for this form and required information that could comprise a submission is 6 hours.

Comments regarding the burden estimate or any other aspect of this form should be directed to the Information Collection Clearance Officer, Bureau of Ocean Energy Management, 45600 Woodland Road, Sterling, VA 20166.

FORM BOEM-1021 (Month/Year) PAGE 3 OF 3

Previous Editions are Obsolete.