Form BOEM-1021 Covered Offshore Facilities

U.S. Department of the Interior
Bureau of Ocean Energy Management

OMB Control No.: 1010-0106
Expiration Date: xx/xx/2023

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

2. The following list comprises all of the

BOEM COMPANY NUMBER

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 OILSPILL
DISCHARGE
(In Barrels)

FORM BOEM-1021 (Month Year)
Previous Editions are Obsolete.

PAGE 1 OF 3

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 OILSPILL
DISCHARGE
(In Barrels)

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

FORM BOEM-1021 (Month Year)
Previous Editions are Obsolete.

PAGE 2 OF 3

U.S. Department of the Interior
Bureau of Ocean Energy Management

OMB Control No.: 1010-0106
Expiration Date: xx/xx/2023

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)

Previous Editions are Obsolete.

PAGE 3 OF 3