Form
Financial Assurance
Declaraon
Page 1 of 6
Reference: N-04730-FM1519
Revision: 2
Revision Date: December 2018
Regulaon 5G of the Oshore Petroleum and Greenhouse Gas Storage (Environment) Regulaons 2009
provides that NOPSEMA must be reasonably sased that a tleholder is compliant with secon 571(2)
of the Oshore Petroleum and Greenhouse Gas Storage Act 2006 prior to accepng an environment plan
(EP) or revised EP.
In accordance with NOPSEMA’s Financial Assurance for Petroleum Titles Guideline (the Guideline)
(N-04730-GL1381), titleholders must provide declarations of compliance with section 571(2) to
NOPSEMA for all petroleum tles on which petroleum acvies are to be undertaken. A Financial
Assurance Declaraon relates to the tles for which the declaraon is made and may be applicable
to mulple acvies and mulple EP submissions for those tles.
A Financial Assurance Declaration can be made to NOPSEMA at any time. A Financial Assurance
Confirmation (N-04730-FM1465) must also be provided by the titleholder undertaking the activity prior
to acceptance of an EP.
Further advice on meeng nancial assurance requirements is provided in the Guideline available on
NOPSEMAs website.
This declaraon must be signed by individuals who;
are the registered holder of the tles to which the declaraon relates; or
are acng with the registered tleholders express or implied authority and on behalf of the
tleholder; or
are acng with power of aorney on behalf of the tleholder.
On receipt of a Financial Assurance Declaraon that contains all of the requisite informaon,
NOPSEMA will provide a nocaon of receipt.
Where a Financial Assurance Declaraon is not provided in a form acceptable to NOPSEMA, the
tleholder(s) will be advised and requested to provide a further declaraon.
Where a tleholder is unable to provide a Financial Assurance Declaraon to NOPSEMA it is
recommended that the tleholder contact NOPSEMAs Environment Division as soon as praccable.
Failure to provide a Financial Assurance Declaraon will
1
prevent NOPSEMA from accepng an EP.
Supplying false or misleading informaon to a Commonwealth Enty is an oence under the
Criminal Code Act 1995 and providing such false informaon may render NOPSEMAs decisions
in accepng EPs which rely on a Financial Assurance Declaraon as invalid.
1
This is a NOPSEMA process requirement and is not a legislave requirement under the OPGGS Act.
Page 2 of 6
Reference: N-04730-FM1519
Revision: 2
Revision Date: December 2018
Financial Assurance Declaraon
Secon 571 Oshore Petroleum Greenhouse Gas Storage Act 2006
1. Titleholder details
Your reference number (if any) for this declaraon:
Reference
Titleholder Name:
(as listed on the tle registered with NOPTA)
Enter text
Titleholder Business Address:
Address line 1
Address line 2
Address line 3
Address line 4
Telephone:
Enter text
Email:
Enter text
Title(s) to which this declaraon relates
2
:
2
This declaration applies to the t
itle(s) listed in the declaration until replaced by a new declaration for the title(s).
RESET FORM
Page 3 of 6
Reference: N-04730-FM1519
Revision: 2
Revision Date: December 2018
Financial Assurance Declaraon
1. A company director, authorised ocer or individual with the registered tleholders express or
implied authority and on behalf of the tleholder.
A. Where there is only one registered tleholder:
For use where a single enty or an individual person is listed as the only registered tleholder of
the tle(s)
(the undersigned) cerfy for all tles to which this Declaraon relates, that
is in and will maintain compliance with the
requirements of secon 571(2) of the Oshore Petroleum and Greenhouse Gas Storage Act 2006.
2. Declaraon (Opon 1 of 3)
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Instrucons: Please select one of the 3 Declaraon opons, cerfy for all tles and sign.
Pares signing the declaraon
also acknowledge that supplying false or misleading informaon to a Commonwealth enty is an
oence under the Criminal Code Act 1995, and that providing such false informaon may render NOPSEMAs
decisions in accepng environment plans for which this declaraon is being made, as invalid.
EXECUTED by:
2. A person appointed under power of aorney on behalf of the tleholder.
This form has been formaed to allow for the use of electronic signatures. Alternavely the form may be printed and signed in blue or black ink
Select
Select
Signature
Name
Posion
At [insert place]
On [insert date]
Signature
Name
Posion
At [insert place]
On [insert date]
Signature of person who is authorised by Power of Aorney
and who declares that he or she has at the me of execuon of
this document no noce of its revocaon
Name of person who is authorised by Power of Aorney Provide number or date, details of registraon (if any)
At [insert place] On [insert date]
Select
Select
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
Page 4 of 6
Reference: N-04730-FM1519
Revision: 2
Revision Date: December 2018
Financial Assurance Declaraon
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2. Declaraon (Opon 2 of 3)
B. Where there are mulple tleholders:
For use where more than one individual and/or enty are listed as the registered holders
of the tle(s) and the tleholders wish to discharge a proporon of the nancial assurance
obligaon that represents their interest in the tle. For further informaon on Financial
Assurance Declaraons for mulple tleholders please see NOPSEMAs Financial Assurance for
Petroleum Titles Guideline
(the undersigned) cerfy for all tles to which this Declaraon relates, that
is in and will maintain compliance with the
requirements of secon 571(2) of the Oshore Petroleum and Greenhouse Gas Storage Act 2006.
also acknowledge that supplying false or misleading informaon to a Commonwealth enty is an
oence under the Criminal Code Act 1995, and that providing such false informaon may render NOPSEMAs
decisions in accepng environment plans for which this declaraon is being made, as invalid.
EXECUTED by:
Instrucons: Please select one of the 3 Declaraon opons, cerfy for all tles and sign.
1. A company director, authorised ocer or individual with the registered tleholders express or
implied authority and on behalf of the tleholder.
Pares signing the declaraon
2. A person appointed under power of aorney on behalf of the tleholder.
This form has been formaed to allow for the use of electronic signatures. Alternavely the form may be printed and signed in blue or black ink
Select
Select
Signature
Name
Posion
At [insert place]
On [insert date]
Signature
Name
Posion
At [insert place]
On [insert date]
Signature of person who is authorised by Power of Aorney
and who declares that he or she has at the me of execuon of
this document no noce of its revocaon
Name of person who is authorised by Power of Aorney Provide number or date, details of registraon (if any)
At [insert place] On [insert date]
Select
Select
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
Page 5 of 6
Reference: N-04730-FM1519
Revision: 2
Revision Date: December 2018
Financial Assurance Declaraon
2. Declaraon (Opon 3 of 3)
C. Where there are mulple tleholders and the nancial assurance obligaons are to be
discharged by a single enty:
For use where more than one individual and/or enty are listed as the registered holders of
the tle(s) and a single tleholder wishes to discharge the enre nancial assurance obligaon
on behalf of all other tleholders.
(the undersigned) cerfy in respect of the obligaons for all tles to which this
Declaraon relates that
i. is in and will maintain compliance with the requirements of secon 571(2) of the
Oshore Petroleum and Greenhouse Gas Storage Act 2006; and
ii. discharges the enre obligaon on behalf of all registered tleholders in accordance with
secon 775D of the Oshore Petroleum and Greenhouse Gas Storage Act 2006.
also acknowledge that supplying false or misleading informaon to a Commonwealth enty is an
oence under the Criminal Code Act 1995, and that providing such false informaon may render NOPSEMAs
decisions in accepng environment plans for which this declaraon is being made, as invalid.
EXECUTED by:
RESET FORM
Instrucons: Please select one of the 3 Declaraon opons, cerfy for all tles and sign.
1. A company director, authorised ocer or individual with the registered tleholders express or
implied authority and on behalf of the tleholder.
Pares signing the declaraon
2. A person appointed under power of aorney on behalf of the tleholder.
This form has been formaed to allow for the use of electronic signatures. Alternavely the form may be printed and signed in blue or black ink
Select
Select
Signature
Name
Posion
At [insert place]
On [insert date]
Signature
Name
Posion
At [insert place]
On [insert date]
Signature of person who is authorised by Power of Aorney
and who declares that he or she has at the me of execuon of
this document no noce of its revocaon
Name of person who is authorised by Power of Aorney Provide number or date, details of registraon (if any)
At [insert place] On [insert date]
Select
Select
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
Page 6 of 6
Reference: N-04730-FM1519
Revision: 2
Revision Date: December 2018
Financial Assurance Declaraon
Privacy Noce
NOPSEMA collects your personal informaon so that it can administer the OPGGS Act and associated regulaons as set out
above. If you do not provide personal informaon, NOPSEMA may not be able to process the declaraon.
NOPSEMA will not use or disclose your personal informaon for any other purpose without your consent, unless it is required
or authorised by law, or if it relates to NOPSEMA’s enforcement acvies. Your personal informaon may be disclosed to the
following organisaons, enes or individuals:
individuals who make a request under the Freedom of Informaon Act 1982
the Australian Naonal Audit Oce and other privately-appointed auditors
other law enforcement bodies (for example, the police or the Coroner)
NOPSEMAs legal advisors.
NOPSEMA may occasionally disclose informaon to overseas recipients in order to discharge its funcons, exercise its powers,
or to perform its necessary business acvies.
Further informaon about how you can access, or seek correcon to, your personal informaon is contained in NOPSEMAs
APP Privacy Policy at www.nopsema.gov.au/privacy. If you have an enquiry or a complaint about your privacy, please contact
NOPSEMAs Privacy Contact Ocer on 08 6188 8700 or by email at privacy@nopsema.gov.au.
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Submissions
Submission of this form to NOPSEMA may be made by:
Secure File Transfer:
https://securefile.nopsema.gov.au/filedrop/submissions
Or
Email: submissions@nopsema.gov.au
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