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APPOINTMENT OF DESIGNATED APPLICANT (Minerals Management Service)

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U.S. Department of the Interior
Bureau of Ocean Energy Management
OMB Control No.:
1010-0106
Expiration Date: 01/31/2023
APPOINTMENT OF DESIGNATED APPLICANT
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
ADDRESS BOEM COMPANY REGION
CITY STATE ZIP CODE
2. Responsible Party
:
COMPANY LEGAL NAME BOEM COMPANY NUMBER
ADDRESS BOEM COMPANY REGION
CITY STATE ZIP CODE
CONTACT PERSON CONTACT PERSON’S TITLE
( ) ( )
AREA CODE and TELEPHONE NUMBER AREA CODE and FAX NUMBER E-MAIL ADDRESS
3. I, the undersigned, serving as the Authorized Representative of the Responsible Party named in section 2, do hereby
appoint and authorize the Designated Applicant identified in section 1 to act on behalf of the Responsible Party to obtain a
certification of oil spill financial responsibility (OSFR) for each covered offshore facility at the locations described in section
5, and to establish and maintain OSFR on the Responsible Party’s behalf for these specified covered offshore facilities in
accordance with 30 CFR Part 553 and in the amounts specified by the Bureau of Ocean Energy Management (BOEM). On
behalf of the Responsible Party, I explicitly agree that the Responsible Party be strictly liable, jointly and severally, together
with the other Responsible Parties for each covered offshore facility described in section 5, for all oil spill removal costs and
damages in accordance with the Oil Pollution Act of 1990, as amended, 33 U.S.C. § 2701 et seq.
This appointment is effective beginning on . I agree, on behalf of the
DATE
Responsible Party, that the Responsible Party will notify the BOEM oil spill financial responsibility program in writing when
this appointment is canceled; that the Responsible Party will concurrently appoint a substitute Designated Applicant; and
that the Responsible Party shall be bound by the actions of the Designated Applicant hereby appointed until such time as
BOEM receives such notice and a substitute Designated Applicant so appointed.
NAME OF AUTHORIZED REPRESENTATIVE SIGNATURE
TITLE OF AUTHORIZED REPRESENTATIVE DATE
4. The Responsible Party’s U.S. Agent for Service of Process is:
NAME
ADDRESS BOEM COMPANY NUMBER
CITY STATE ZIP CODE
( ) ( )
AREA CODE and TELEPHONE NUMBER AREA CODE and FAX NUMBER E-MAIL ADDRESS
PAGE 1 OF 3
FORM BOEM-1017 (January 2020)
Previous Editions are Obsolete.
5. Locations of Covered Offshore Facilities:
STATE
OR
OCS
REGION
LEASE
NUMBER
ALIQUOT
PORTION
(If Applicable)
DEPTH
RANGE
(If Applicable)
AREA
NAME
BLOCK
NUMBER
RUE OR
ROW
NUMBER
PIPELINE
SEGMENT
NUMBER
PA
GE 2 OF 3
FORM BOEM-1017 (January 2020)
Previous Editions are Obsolete.
U.S. Department of the Interior
Bureau of Ocean Energy Management
OMB Control No.: 1010-0106
Expiration Date: 01/31/2023
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 9 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.
PA
GE 3 OF 3
FORM BOEM-1017 (January 2020)
Previous Editions are Obsolete.
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APPOINTMENT OF DESIGNATED APPLICANT (Minerals Management Service)

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Completed 26 September 2021

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