BOEM-0003 OCS Renewable Energy Assignment of Interest in Lease

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

OMB Control No.: 1010-0176
Expiration Date: xx/xx/202x

Lease No.

ASSIGNMENT OF RECORD TITLE INTEREST IN
FEDERAL OCS RENEWABLE ENERGY LEASE
Lease Effective Date

Part A: Assignment
This assignment is made with respect to the block(s) and/or aliquot part(s) described in Exhibit “A” attached hereto
and made a part hereof.

Assignor(s) does hereby sell, assign, transfer and convey unto Assignee(s) the following undivided
right, title and interest (insert name and qualification number of each Assignor and Assignee below):
Assignor(s):

Percentage Interest Conveyed

Assignee(s):

Percentage Interest Received

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Exhibit “B,” which sets forth other provisions between Assignor(s) and Assignee(s), is attached to and
made a part of this assignment.
For BOEM Use only – Do Not Type Below This Line
This Assignment of Record Title Interest has been filed as of the date stamped on this document and
hereby approved by the Bureau of Ocean Energy Management on the date below.
By__________________________________
Authorized Official for BOEM

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Title

____________________
Approval Date

Paperwork Reduction Act of 1995 (PRA) Statement: The PRA (44 U.S.C. 3501 et seq.) requires us to inform you that we collect this
information to use in the adjudication process involved in leasing and lease operations. The BOEM uses the information to track ownership of
leases in the OCS. Responses are required to obtain or retain a benefit. Release of such data and information is covered under 30 CFR
585.113. 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 OMB Control Number. Public reporting burden of this form is estimated to average 30 minutes per response, including the time for
reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Direct comments regarding the burden estimate
or any other aspect of this form to the Information Collection Clearance Officer, Bureau of Ocean Energy Management, 45600 Woodland Road,
Sterling, Virginia 20166.

Form BOEM-0003 (Month Year) Previous Editions are Obsolete.

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Part B – Certification and Acceptance
1.

Each Assignor certifies it is the owner of the interest in the above-described lease that is hereby assigned to the Assignee(s) specified
above.

2.

DEBARMENT COMPLIANCE: Assignee shall comply with the Department of the Interior’s nonprocurement debarment and
suspension regulations as required by Subpart B of 2 CFR Part 1400 and shall communicate the requirement to comply with these
regulations to persons with whom it does business related to this interest assignment by including this term in its contracts and
transactions.

3.

EQUAL OPPORTUNITY AND AFFIRMATIVE ACTION COMPLIANCE CERTIFICATION: Assignor(s) and Assignee(s)
certify that they are in full compliance with Equal Opportunity Executive Order 11246, as amended, and the implementing regulations at
41 CFR 60-01 – Obligations of Contractors and Subcontractors; and 41 CFR 60-2 – Affirmative Action Programs. These requirements
are for the purpose of preventing discrimination against persons on the basis of race, color, religion, sex, or national origin. These
regulations have specific performance requirements.

4.

Assignee’s execution of this assignment constitutes acceptance of all applicable terms, conditions, stipulations and restrictions pertaining
to the lease described herein. Applicable terms and conditions include, but are not limited to, an obligation to conduct all operations on
the leasehold in accordance with the terms and conditions of the lease, to restore the leased lands upon completion of any operations as
described in the lease, and to furnish and maintain bond(s) pursuant to regulations at 30 CFR Part 585. This assignment is subject to the
Outer Continental Shelf Lands Act of August 7, 1953, 43 U.S.C. 1331 et seq., as amended (the “Act”), and Assignee(s) is subject to, and
shall fully comply with, all applicable regulations now or to be issued under the Act. Notwithstanding any agreement between the
Assignor(s) and Assignee(s), the parties’ liability to the Bureau of Ocean Energy Management is governed by 30 CFR Part 585.

This Assignment of Interest will be made effective between the parties hereto as of _______________, upon approval by the Bureau of Ocean
Energy Management, United States Department of the Interior.
This instrument may be executed in any number of counterparts, each of which will be deemed an original instrument, but all of which together
shall constitute but one and the same instrument provided, however, this instrument and any other counterpart hereof, will not be binding
unless and until executed by all of the parties, and will not be accepted by the Bureau of Ocean Energy Management unless all counterparts are
filed simultaneously.
I certify that the statements made herein by the undersigned are true, complete and correct to the best of my knowledge and belief and are made
in good faith.
Title 18 U.S.C. 1001 makes it a crime for any person knowingly and willfully to make to any Department or agency of the United States any
false, fictitious or fraudulent statements or representations as to any matter within its jurisdiction.

Assignor Name:
Assignor Qualification No.

Assignor Name:
Assignor Qualification No.

By: ________________________________
Signatory Name:
Signatory Title:

By: _________________________________
Signatory Name:
Signatory Title:

___________________________________
Execution Date

_____________________________________
Execution Date

Assignee Name:
Assignee Qualification No.

Assignee Name:
Assignee Qualification No.

By: ________________________________
Signatory Name:
Signatory Title:

By: _________________________________
Signatory Name:
Signatory Title:

___________________________________
Execution Date

____________________________________
Execution Date

Attach Notary Acknowledgement (not mandatory)
Form BOEM-0003 (Month Year) Previous Editions are Obsolete.

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EXHIBIT “A”
ASSIGNMENT OF RECORD TITLE INTEREST IN
FEDERAL OCS RENEWABLE ENERGY LEASE

The Assignment is made with respect to the following described block(s) and/or aliquot part(s) of the lease:

Area Name or
Protraction Diagram

Block

Subdivision or Aliquot Part
(If entire block, enter “All”)

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Form BOEM-0003 (Month Year) Previous Editions are Obsolete.

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