Form BOEM-1123 Designation of Operator

OMB Control No: 1010-0114
Expiration Date: xx/xx/202x

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

DESIGNATION OF OPERATOR
The person identified below is, on the records of the Bureau of Ocean Energy Management, a lessee and/or operating rights
owner of:
Lease Number: ______________
Regional Office: ___________________________

__________________________
Qualification Number
of Designated Operator

and hereby designates

Name of Operator: ___________________________________________________________________
Address: ___________________________________________________________________________
as the designated operator and agent with full authority to act on the lessee’s/operating rights owner’s behalf, to fulfill the lessee’s/
operating rights owner’s obligations under the OCS Lands Act, in compliance with the terms and conditions of the lease, laws and
applicable regulations. The BOEM Regional Supervisor or the authorized BOEM Regional Officer may provide the designated
operator written or oral instructions in securing compliance with the lease, laws, and applicable regulations. This designation of
operator is made with respect to (describe block or aliquot portion of the lease’s area and depth, if appropriate, to which this
designation applies):
Check here if description continued on attached sheet.

It is understood that this designation of operator does not relieve the lessee/operating rights owner of responsibility for
compliance with the terms of the lease, laws, and applicable regulations. It is also understood that this designation of
operator does not constitute an assignment of any interest in the lease.
In case of default on the part of the designated operator, the lessee/operating rights owner will make full and prompt compliance
with all laws, regulations, lease terms, or orders of the Secretary of the Interior or his/her representative. If BOEM determines the
operator’s performance being conducted on the leased area described above is unacceptable, BOEM may disqualify the operator,
or may disapprove or revoke your designation of operator. The operator will be given adequate notice and opportunity for a review
by BOEM Regional officials before initiating or imposing a disqualification. The BOEM Regional Director may require the lessee/
operating rights owner to designate an agent empowered to fulfill the lessee’s/operating rights owner’s obligations under the OCS
Lands Act, the lease, or governing regulations.
The lessee/operating rights owner agrees to notify the Regional Supervisor promptly of any change in the designated operator.
The designated operator shall comply with the Department of the Interior’s nonprocurement debarment and suspension
regulations as required by Subpart A of 2 CFR Part 180 and 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 designation by including this
term in its contracts and transactions.
___________________________________________________
Name of Designated Operator

___________________________________________________
Name of Lessee/Operating Rights Owner

___________________________________________________
Qualification Number of Operator

___________________________________________________
Qualification Number of Lessee/Operating Rights Owner

________________________________________________________
Authorized Signature of Operator

_________________________________________________________
Authorized Signature of Lessee/Operating Rights Owner

Signatory Name: _____________________________________

Signatory Name: _____________________________________

Signatory Title: ____________________________________________

Signatory Title: ____________________________________________

Date: ______________________________________________

Date: ______________________________________________

Paperwork Reduction Act of 1995 (PRA) Statement: The PRA (44 U.S.C. 3501 et seq.) requires us to inform you that BOEM collect t his information to be informed
of who is authorized to act on behalf of the lessees/operating rights owners to fulfill their obligations under the OCS Lands Act, lease, and applicable
regulations, and who is authorized to receive notices and comply with regulatory orders issued. Responses are mandatory (43 U.S.C. 1331 et seq.). No proprietary
information is collected. An agency may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a currently valid
OMB Control Number. Public reporting burden for 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. You may 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 Rd, Sterling, VA 20166.

Form BOEM-1123 (Month Year)
Previous Editions are Obsolete.

Page 1 of 1