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FINANCIAL GUARANTEE CERTIFICATION OF OIL SPILL FINANCIAL RESPONSIBILITY (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
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, 33 U.S.C. § 2701 et seq. (hereinafter called OPA), 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 Title 30 part 553 of the Code of Federal Regulations (CFR).
This 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: ____________________.
6. The Financial Guarantor may at any time give notice of intent to cancel this Guarantee by written notice
sent by certified mail to the Designated Applicant with copies (plainly indicating the original notice was sent
by certified mail) to all Responsible Parties and to the BOEM oil spill financial responsibility program by
certified mail. This instrument will remain in force and the undersigned will remain liable until the expiration
date above or until the earlier of: (1) thirty calendar days after Bureau of Ocean Energy Management
(BOEM) and the Designated Applicant receive from the instrument issuer a notification of intent to cancel;
(2) BOEM receives other acceptable OSFR evidence from your Designated Applicant; or (3) all the COFs
to which the instrument applies are permanently 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 Financial Guarantor for claims arising from an incident (i.e., oil discharge or
substantial threat of the discharge of oil) that occurs on or before the effective date of termination of this
Guarantee.
PAGE 1 OF 5
FORM BOEM-1023 (January 2020)
Previous Editions are Obsolete.
The undersigned agrees that any suit or claim for which any Responsible Parties identified in form(s)
BOEM-1017, on file or attached, represented by the aforementioned Designated Applicant may be liable
under Title I of 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.
The undersigned further agrees not to use any defenses except those that would be available to a Responsible
Party for whom the Guarantee was provided or that the incident (i.e., oil discharge or a substantial threat of the
discharge of oil) leading to the claim for removal costs or damages was caused by willful misconduct of a
Responsible Party for whom the Designated Applicant demonstrated OSFR.
7. Financial Guarantor providing evidence of oil spill financial responsibility in the form of a Guarantee.
__________________________________
COMPANY LEGAL NAME
_________________________________
BOEM COMPANY NUMBER
_________________________________________________________________________________________________________
ADDRESS
__________________________________
C ITY
____________________________
STATE
________________________
ZIP CODE
__________________________________
CONTACT PERSON FOR CLAIMS
________________________
CONTACT PERSON’S TITLE
___________________________________
AREA CODE AND TELEPHONE NUMBER
____________________________
AREA CODE AND FAX NUMBER
________________________
E-MAIL ADDRESS
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.
SIGNATURE
DATE
9. The Financial Guarantor’s U.S. Agent for Service of Process is:
__________________________________
NAME
_________________________________
BOEM COMPANY NUMBER
_________________________________________________________________________________________________________
ADDRESS
__________________________________
CITY
____________________________
STATE
________________________
ZIP CODE
___________________________________
AREA CODE AND TELEPHONE NUMBER
____________________________
AREA CODE AND FAX NUMBER
________________________
E-MAIL ADDRESS
PAGE 2 OF 5
FORM BOEM-1023 (January 2020)
Previous Editions are Obsolete.
10. 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.
11. 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.
12. 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
PAGE 3 OF 5
FORM BOEM-1023 (January 2020)
Previous Editions are Obsolete.
BOEM ID
NUMBER
RESPONSIBLE PARTIES COVERED BY THIS AGREEMENT
PAGE 4 OF 5
FORM BOEM-1023 (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 1.5 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.
PAGE 5 OF 5
FORM BOEM-1023 (January 2020)
Previous Editions are Obsolete.
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Completed 26 September 2021

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