Form ONRR-4425 Designation Form for Payment Responsibility

U.S. Department of the Interior Office of Natural Resources Revenue

OMB Control Number 1012-0008 Approval Expires: XX/XX/XXXX

Form ONRR-4425

Designation Form for Payment Responsibility

(1) FILING TYPE: INITIAL_______ MODIFICATION________ TERMINATION_________

(2) AGENCY ASSIGNED LEASE NUMBER(S):___________________________________________________

(3) PRODUCT TYPE: OIL___ GAS___ COAL___ SOLID MINERALS___ GEOTHERMAL___

(4) PAYMENT TYPE: RENT_______ MINIMUM ROYALTY________ ROYALTY _________ OTHER_______

INFORMATION TO BE PROVIDED BY LESSEE:

(5) PAYOR CODE:___________________ (6) TAX IDENTIFICATION NUMBER:______________________

(7) LESSEE NAME:___________________________________________________________________________________

ADDRESS:_______________________________________________________________________________________

EMAIL ADDRESS:________________________________________________________________________________

TELEPHONE:________________

INFORMATION TO IDENTIFY DESIGNEE:

(8) PAYOR CODE:___________________ (9) TAX IDENTIFICATION NUMBER:_____________________

(10) DESIGNEE NAME:___________________________________________________________________________

ADDRESS:__________________________________________________________________________________

EMAIL ADDRESS:___________________________________________________________________________

TELEPHONE:______________________

(11) INDIVIDUAL TO CONTACT FOR THE DESIGNEE IF A COMPANY IS IDENTIFIED IN ITEM 10:

NAME:_____________________________________________________________________________________

ADDRESS:__________________________________________________________________________________

EMAIL ADDRESS:___________________________________________________________________________

TELEPHONE:______________________

PLEASE PROVIDE YOUR OWNERSHIP IN THE LEASE AND WRITTEN DESIGNATION:

(12) LESSEE OF RECORD: YES ___ NO____

(13) OPERATING RIGHTS OWNER: YES ___ NO___

(14) OPERATING RIGHTS PERCENTAGE: _______

(15) LESSEE MUST PROVIDE A WRITTEN DESIGNATION, SIGNED AND DATED BY LESSEE AND DESIGNEE.

LESSEE SIGNATURE:

(16) SIGNATURE:________________________________ DATE:________________________________

General Instructions for Form ONRR-4425

Form ONRR-4425 is used by a lessee to designate a designee for payment responsibility for a Federal or Indian oil, gas, coal, solid minerals, or geothermal lease. If you are a lessee who pays your own royalty or contracts a third party to pay on your behalf under your unique payor ID, no form ONRR-4425 is required. Please submit the completed form(s) and attachments pursuant to the instructions located on ONRR’s website at https://onrr.gov/references/forms.

Line-by-Line Instructions

(All items are mandatory except as otherwise noted below)

1. Filing Type – If this is the initial filing, check “initial.” If this is a modification of an initial filing, check “modification.” If this is a termination of a designation, check “termination.” All initial filings, modifications, and terminations are effective upon receipt by ONRR in the manner specified on ONRR’s website at https://onrr.gov/references/forms.

2. Agency Assigned Lease Number - an alpha-numeric number assigned to any lease issued or approved by the U.S. under a mineral leasing law that authorizes exploration for, extraction of, or removal of minerals. You may file this form for multiple leases. You must specify all the leases that this designation covers in your written designation acceptance letter when completing item 15 below, specifying for each lease the information called for in item nos. 1-4 and 12-14. The information supplied in item nos. 5-11 and 15-16 applies to each lease.

3. Product Type - List the types of products covered by the designation.

4. Responsibility Type - Check one or more of the payments responsibility types covered by the designation. If you check “other,” you must specify the other responsibility type when completing item 15 below.

(If the product type and payment type are not completed, the form ONRR-4425 will be treated as a designation of responsibility for all payment and product types)

5. Lessee ONRR Payor Code – a 5-digit code assigned by ONRR to the lessee (30 U.S.C. § 1702). A lessee does not include a person who merely operates a lease and is responsible for filing production reports under 30 C.F.R. § 1210.101.

6. Lessee Tax Identification Number (TIN) - a 9-digit number that is your employer identification number (EIN). ONRR cannot accept a Social Security Number as a TIN. You may obtain a Federal tax ID number online from the IRS or by filing an IRS Form SS-4, Application for Employer Identification Number.

7. Lessee name, physical address, email address, and telephone.

8. Designee ONRR Payor Code - a 5-digit code assigned to the designee who is assuming the specified payment obligation on the lessee’s behalf on the lease(s).

9. Designee Tax Identification Number - a 9-digit number that is your employer identification number (EIN). ONRR cannot accept a Social Security Number as a TIN. You may obtain a Federal tax ID number online from the IRS or by filing an IRS Form SS-4, Application for Employer Identification Number.

10. Designee name, address, email address, and telephone.

11. Enter an individual to contact for the designee if a company is identified in item 10 above.

12. Enter yes or no if the lessee filing this form is a lessee of record (record title owner) for the lease(s). (30 USC 1702 and 1712(a)).

13. Enter yes or no if the lessee filing this form owns operating rights in the lease(s). (30 USC 1702 and 1712(a)).

14. If you are an operating rights owner, enter your percentage of operating rights in the lease. If you have different operating rights percentages for different areas covered by the lease, please specify this information in a written designation when completing item 15 below. Pursuant to 30 CFR 1218.52(d), ONRR requires you to provide notice when there is a change in the percentage of your record title or operating rights ownership.

15. You must file with your form ONRR-4425 a copy of a written designation acceptance letter signed by both the lessee and the designee. The written designation must specify all leases for which the designation is made. The written designation acceptance letter may be signed electronically. The form ONRR-4425 filing will be incomplete, and thus not effective, without signatures of both the lessee and designee, as well as all other information required under Instruction Nos. 4 and 14.

16. Enter signature of the lessee (not the designee). The Form ONRR-4425 may be signed electronically.

Paperwork Reduction Act of 1995 (PRA) Statement: The PRA (44 U.S.C. 3501 et seq.) requires ONRR to inform you that we collect this information to identify who is responsible for making royalty and related payments on leases. The Federal Oil and Gas Royalty Simplification and Fairness Act of 1996 (Public Law 104-185) clearly establishes the owners of operating rights and/or lease record title as responsible for making royalty and related payments on a Federal lease. ONRR uses the information that payors provide, regarding the lessees on whose behalf that they are paying, to determine if we need to inform those lessees that they must certify to ONRR in writing their respective payors as their designees. Responses are voluntary; however, failure to provide the mandatory information required by the form and 30 C.F.R. § 1218.52(a)(1-10), will prevent a lessee from designating a person to make royalty payments on its behalf. See 30 U.S.C. § 1712(a); see also 30 C.F.R. §§ 1210.158 and 1218.52." Proprietary information is protected in accordance with standards established by the Federal Oil and Gas Royalty Management Act of 1982 (30 U.S.C. 1733), the Freedom of Information Act [5 U.S.C. 552(b)(4)], and the Department regulations (43 CFR 2). 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 for this form is estimated to average 0.75 hour 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 ONRR Rules & Regs Team, PO Box 25165, MS 64000A, Denver, CO 80225.

Privacy Act Statement: This system contains information protected under the provisions of the Privacy Act of 1974 (Public Law 93-579). Authority: This information is being solicited under the authority of The Federal Oil and Gas Royalty Management Act of 1982, 30 U.S.C. 1701-1759; Chapter 12 of Title 25 of the U.S. Code, addressing the lease, sale, or surrender of allotted or unallotted lands, found at 25 U.S.C. 391-416j; Chapter 3A of Title 30 of the U.S. Code, addressing leases and prospecting permits, found at 30 U.S.C. 181-196; and the Outer Continental Shelf Lands Act, 43 U.S.C. 1331-1356b. Purpose: The primary purpose for collecting this information is to collect royalties and rents; control revenues; distribute funds collected; maintain records of royalty accounts and associated sales, and production information. Routine Uses: The routine use of this data is to facilitate comparative auditing of mineral production, royalties due, revenues collected, and funds distributed; gather statistics for managing the mineral leasing program; provide informational access to external users including states, Indian tribes or agencies, and Federal agencies; and provide outreach services to the Indian community. Citation: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, all or a portion of the records or information contained in this system may be disclosed outside DOI as a routine use pursuant to 5 U.S.C. 552a(b)(3) as found in the published system of records notice, Minerals Revenue Management Support System (MRMSS), OS-30 (Replaces MMS-1) - March 25, 2016, 81 FR 16207, which may be viewed at: Furnishing the information on the form is voluntary; however, failure to provide the mandatory information required by the form and 30 C.F.R. § 1218.52(a)(1-10), will prevent a lessee from designating a person to make royalty payments on its behalf. See 30 U.S.C. § 1712(a); see also 30 C.F.R. §§ 1210.158 and 1218.52.