Financial Guarantee

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

OMB Control No.: 1010-0106
Expiration Date: 00/00/202#

FINANCIAL GUARANTEE
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 Responsible Parties, identified in form(s) BOEM-1017 on file or attached, and

,
NAME OF ENTITY

a

created under the laws of
TYPE OF ENTITY

,
STATE

and authorized to do business in the United States, as Guarantor, (hereinafter called Guarantor), agree to be
jointly and severally liable to the United States of America and other claimants for damages and removal costs
under the Oil Pollution Act of 1990, as amended, see 33 U.S.C. §§ 2701-2720 (hereinafter, OPA or the Act), in
the sum indicated in section 4, for which payment our heirs, executors, administrators, successors, and assigns
will also be liable, under the terms and conditions of Part 553 of Title 30 of the Code of Federal Regulations
(CFR).
This Financial Guarantee is hereby provided on behalf of the Responsible Parties to comply with the requirements
of 33 U.S.C. § 2716(c) and is offered to satisfy any claim made under OPA.
3. For the purpose of this application, the undersigned is acting in the capacity of a Financial Guarantor
in accordance with the requirements of 30 CFR 553.32.
4. The amount of coverage for which evidence of oil spill financial responsibility (OSFR) is being
established is:

$

5. This coverage is effective:

and expires on the first calendar day of the fifth month after the
DATE

close of the Financial Guarantor’s fiscal year, which ends:

.
DATE

The Financial Guarantee evidenced by this Certificate will be applicable only in relation to each incident (as
defined by 33 U.S.C. § 2701(14)) that first occurs on or after the effective date of this Financial Guarantee and
on or before the termination date of this Financial Guarantee, and will be applicable only in relation to each
incident giving rise to claims under the Act. Under no circumstance will a Financial Guarantee Certificate that
expires or is terminated prior to or takes effect after the commencement of an incident apply to that incident.
6.The named Financial Guarantor may at any time give notice of intent to terminate this Guarantee in
accordance with the Act and its implementing regulations by written notice sent by certified mail to the
Designated Applicant with copies (plainly indicating the original notice was sent by certified mail) to any
Responsible Party and to the Bureau of Ocean Energy Management (BOEM) oil spill financial
responsibility program. This instrument will remain in force until the earlier of either the expiration date
or the following: (1) thirty calendar days after BOEM and the Designated Applicant receive from the
named Financial Guarantor a notification of intent to terminate this Financial Guarantee; (2) BOEM
receives other acceptable OSFR evidence from your Designated Applicant; or
(3) all the Covered Offshore Facilities to which the instrument applies are permanently and
appropriately abandoned in compliance with 30 CFR Part 250 or equivalent state requirements. The
undersigned agrees that termination of this instrument will not affect the liability of the named Financial
Guarantor for claims arising from an incident that first occurs on or after the effective date of this
Financial Guarantee and on or before the effective date of the termination of this Financial Guarantee.
FORM BOEM-1023 (Month 202#) Previous Editions are Obsolete.
In accordance with 5 CFR 1320.10, BOEM is authorized to continue sponsoring this
collection of information while the renewal submission is pending with OMB.
PAGE 1 OF 5

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

OMB Control No.: 1010-0106
Expiration Date: 00/00/202#

The named Financial Guarantor agrees that any suit or claim for which any Responsible Party(ies)
identified in form(s) BOEM-1017 (on file or attached), may be liable under the Act may be brought
directly against the Financial Guarantor for claims up to the amount of the penalty asserted by the U.S.
government or other claimants when a Responsible Party denies or fails to pay a claim on the basis of
insolvency or a Responsible Party has petitioned for bankruptcy under Title 11 of the U.S. Code. In any
such suit or claim brought against the named Guarantor, the Guarantor’s obligations under the Act and
its implementing regulations arising from this Guarantee are limited to the amount of the Guarantee
identified in this instrument.
The undersigned further agrees that in defending a claim brought against the Guarantor, the Guarantor may only
invoke all rights and defenses that would be available to the Responsible Party under the Act, including that the
incident was caused by the willful misconduct of the Responsible Party.
7. The Financial Guarantor that is providing evidence of oil spill financial responsibility in the form of a Guarantee is:
COMPANY LEGAL NAME

BOEM COMPANY NUMBER

ADDRESS

C ITY

STATE

ZIP CODE

CONTACT PERSON FOR CLAIMS

AREA CODE AND TELEPHONE NUMBER

CONTACT PERSON’S TITLE

E-MAIL ADDRESS

AREA CODE AND FAX NUMBER

8. The undersigned, as an Authorized Representative of the above-named Financial Guarantor, certifies on
behalf of the Financial Guarantor that the requirements set forth in 30 CFR Part 553, and specifically

§§ 553.20, 553.23-28, 553.30 and 553.40 have been met, and further agrees that the Financial
Guarantor, pursuant to the requirements of 30 CFR 553.15, will notify the BOEM oil spill
financial responsibility program in the event that the Financial Guarantor is no longer able to
maintain evidence of oil spill financial responsibility to the extent stated in section 4 above.
___________________________________

___________________________

NAME

SIGNATURE

___________________________________

___________________________

TITLE

DATE

9. The Financial Guarantor’s U.S. Agent for Service of Process is:
NAME

BOEM COMPANY NUMBER

ADDRESS

CITY

AREA CODE AND TELEPHONE NUMBER

STATE

AREA CODE AND FAX NUMBER

ZIP CODE

E-MAIL ADDRESS

FORM BOEM-1023 (Month 202#) Previous Editions are Obsolete.
In accordance with 5 CFR 1320.10, BOEM is authorized to continue sponsoring this
collection of information while the renewal submission is pending with OMB.
PAGE 2 OF 5

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

OMB Control No.: 1010-0106
Expiration Date: 00/00/202#

10. Any changes or modifications reflected in this Financial Guarantee (Form BOEM-1023) apply prospectively only and
do not affect the validity, applicability, or effect of any previous version(s) of this Financial Guarantee form that a named
Guarantor or Responsible Party may have signed and do not affect claims that the Department of the Interior or other
federal government agencies or entities may have against a named Guarantor or Responsible Party based on any
previous version(s) of the Financial Guarantee that a named Guarantor or Responsible Party may have signed.
11. In the event of any conflict or inconsistency between the following: (1) Form BOEM-1023; and (2) the Act and the Act’s
applicable promulgated regulations; the applicable provisions of the Act and promulgated regulations will prevail.
12. The liability of the Financial Guarantor will not be discharged by any payment or succession of payments made,
unless and until such payment or payments will amount in the aggregate to the amount of the Guarantee. In no event
will the Financial Guarantor’s obligation exceed the amount of the Guarantee, provided the Financial Guarantor
furnishes timely written notice to the BOEM oil spill financial responsibility program of all claims filed, judgments
rendered, and payments made by the Financial Guarantor under this Guarantee.
13. The Designated Applicant must, no later than the first calendar day of the fifth month after the close of your Financial
Guarantor’s fiscal year or expiration if earlier, submit either a renewal of this Financial Guarantee or other acceptable
evidence of financial responsibility.
14. In witness whereof, the Designated Applicant for the Responsible Parties and the Financial Guarantor have executed
this instrument on the _____day of __________________ ______________ .
MONTH

YEAR

Designated Applicant for the Responsible Parties named herein:

SIGNATURE OF AUTHORIZED REPRESENTATIVE

NAME OF AUTHORIZED REPRESENTATIVE

TITLE OF AUTHORIZED REPRESENTATIVE

Financial Guarantor:

SIGNATURE

NAME

TITLE

FORM BOEM-1023 (Month 202#) Previous Editions are Obsolete.
In accordance with 5 CFR 1320.10, BOEM is authorized to continue sponsoring this
collection of information while the renewal submission is pending with OMB.
PAGE 3 OF 5

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

BOEM ID
NUMBER

OMB Control No.: 1010-0106
Expiration Date: 00/00/202#

RESPONSIBLE PARTIES COVERED BY THIS AGREEMENT

FORM BOEM-1023 (Month 202#) Previous Editions are Obsolete.
In accordance with 5 CFR 1320.10, BOEM is authorized to continue sponsoring this
collection of information while the renewal submission is pending with OMB.

PAGE 4 OF 5

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

OMB Control No.: 1010-0106
Expiration Date: 00/00/202#

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 1.5 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-1023 (Month 202#) Previous Editions are Obsolete.
In accordance with 5 CFR 1320.10, BOEM is authorized to continue sponsoring this
collection of information while the renewal submission is pending with OMB.

PAGE 5 OF 5