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DESIGNATED APPLICANT INFORMATION CERTIFICATION (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
DESIGNATED APPLICANT INFORMATION CERTIFICATION
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
( )
CONTACT PERSON AREA CODE and TELEPHONE NUMBER
( )
CONTACT PERSON’S TITLE AREA CODE and FAX NUMBER
2. Sum
mary of Evidence of Oil Spill Financial Responsibility:
E-MAIL ADDRESS
Type of Evidence Amount (in U.S. Dollars) Effective Date of Evidence Expiration Date of Evidence
■ Self-Insurance (BOEM-1018) $
■ Financial Guarantee (BOEM-1023) $
■ Surety Bonds (BOEM-1020) $
■ Insurance (BOEM-1019) $
■ Other $
TOTAL AMOUNT $
3. The Designated Applicant, for all of the Responsible Parties whose Designated Applicant authorizations (form BOEM-1017)
are on file or attached, agrees to establish and maintain oil spill financial responsibility (OSFR), under the Oil Pollution Act of
1990, as amended, 33 U.S.C. § 2701 et seq., for all said Responsible Parties. This OSFR will be maintained continuously
for those leases, permits, rights of use and easement, and pipeline segments identified in form(s) BOEM-1017 on file or
attached. I will immediately notify the Responsible Parties of any claims that I receive. I will immediately notify the BOEM
OSFR program if information on this form changes. I certify the information contained herein, including all the information on
the attached forms, is complete, true, and correct to the best of my information and knowledge.
NAME OF AUTHORIZED REPRESENTATIVE SIGNATURE
TITLE OF AUTHORIZED REPRESENTATIVE DATE
4. The Designated Applicant’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 2
FORM BOEM-1016 (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 1 hour.
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.
PAGE 2 OF 2
FORM BOEM-1016 (January 2020)
Previous Editions are Obsolete.
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DESIGNATED APPLICANT INFORMATION CERTIFICATION (Minerals Management Service)

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Completed 26 September 2021

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