FORM
National Offshore Petroleum Safety and Environmental Management Authority N-04730-FM1519 A394812 14/07/2020 Page 1 of 6
Form
Financial Assurance Declaration
Document No: N-04730-FM1519 A394812
Date: 14/07/2020
Regulation 5G of the Offshore Petroleum and Greenhouse Gas Storage (Environment) Regulations 2009 provides
that NOPSEMA must be reasonably satisfied that a titleholder is compliant with section 571(2) of the Offshore
Petroleum and Greenhouse Gas Storage Act 2006 prior to accepting 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 titles on which petroleum activities are to be undertaken. A Financial Assurance Declaration relates to
the titles for which the declaration is made and may be applicable to multiple activities and multiple EP submissions
for those titles.
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 meeting financial assurance requirements is provided in the Guideline available on NOPSEMA’s
website.
This declaration must be signed by individuals who;
are the registered holder of the titles to which the declaration relates; or
are acting with the registered titleholder’s express or implied authority and on behalf of the titleholder; or
are acting with power of attorney on behalf of the titleholder.
On receipt of a Financial Assurance Declaration that contains all of the requisite information, NOPSEMA will provide
a notification of receipt.
Where a Financial Assurance Declaration is not provided in a form acceptable to NOPSEMA, the titleholder(s) will be
advised and requested to provide a further declaration.
Where a titleholder is unable to provide a Financial Assurance Declaration to NOPSEMA it is recommended that the
titleholder contact NOPSEMA’s Environment Division as soon as practicable.
Failure to provide a Financial Assurance Declaration will1 prevent NOPSEMA from accepting an EP.
Supplying false or misleading information to a Commonwealth Entity is an offence under the Criminal Code Act 1995
and providing such false information may render NOPSEMA’s decisions in accepting EPs which rely on a Financial
Assurance Declaration as invalid.
1
This is a NOPSEMA process requirement and is not a legislative requirement under the OPGGS Act.
Financial Assurance Declaration
Form
National Offshore Petroleum Safety and Environmental Management Authority N-04730-FM1519 A394812 14/07/2020 Page 2 of 6
Section 571 Offshore Petroleum Greenhouse Gas Storage Act 2006
1. Titleholder details
Your reference number (if any)
for this declaration:
Reference
Titleholder Name:
(as listed on the title 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 declaration
relates
2
:
2
This declaration applies to the title(s) listed in the declaration until replaced by a new declaration for the title(s).
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Financial Assurance Declaration
Form
National Offshore Petroleum Safety and Environmental Management Authority N-04730-FM1519 A394812 14/07/2020 Page 3 of 6
2. Declaration (Option 1 of 3)
Instructions: Please select one of the 3 Declaration options, certify for all titles and sign.
A.
For use where a single entity or an individual person is listed as the only registered titleholder of the
title(s)
is in and will maintain compliance with the requirements of
Choose an item. also acknowledge that supplying false or misleading information to a Commonwealth
entity is an offence under the Criminal Code Act 1995, and that providing such false information may
render NOPSEMA’s decisions in accepting environment plans for which this declaration is being made, as
invalid.
EXECUTED by:
Parties signing the declaration
This form has been formatted to allow for the use of electronic signatures. Alternatively the form may be printed and signed in blue
or black ink
1. A company director, authorised officer or individual with the registered titleholders express or
implied authority and on behalf of the titleholder.
Signature Signature
Name Name
Position Position
At [insert place] At [insert place]
On [insert date] On [insert date]
2. A person appointed under power of attorney on behalf of the titleholder
Signature of person who is authorised by Power of Attorney
and who declares that he or she has at the time of execution
of this document no notice of its revocation
Name of person who is authorised by Power of Attorney Provide number or date, details of registration (if any)
At [insert place] On [insert place]
We
We
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signature
click to edit
click to sign
signature
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click to sign
signature
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Financial Assurance Declaration
Form
National Offshore Petroleum Safety and Environmental Management Authority N-04730-FM1519 A394812 14/07/2020 Page 4 of 6
2. Declaration (Option 2 of 3)
Instructions: Please select one of the 3 Declaration options, certify for all titles and sign.
B.
For use where more than one individual and/or entity are listed as the registered holders of the
title(s) and the titleholders wish to discharge a proportion of the financial assurance obligation that
represents their interest in the title. For further information on Financial Assurance Declarations for
is in and will maintain compliance with the requirements of
Choose an item. also acknowledge that supplying false or misleading information to a Commonwealth
entity is an offence under the Criminal Code Act 1995, and that providing such false information may
render NOPSEMA’s decisions in accepting environment plans for which this declaration is being made, as
invalid.
EXECUTED by:
Parties signing the declaration
This form has been formatted to allow for the use of electronic signatures. Alternatively the form may be printed and signed in blue
or black ink
1. A company director, authorised officer or individual with the registered titleholders express or
implied authority and on behalf of the titleholder.
Signature Signature
Name Name
Position Position
At [insert place] At [insert place]
On [insert date] On [insert date]
2. A person appointed under power of attorney on behalf of the titleholder
Signature of person who is authorised by Power of Attorney
and who declares that he or she has at the time of execution
of this document no notice of its revocation
Name of person who is authorised by Power of Attorney Provide number or date, details of registration (if any)
At [insert place] On [insert place]
We
We
Reset Form
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
Financial Assurance Declaration
Form
National Offshore Petroleum Safety and Environmental Management Authority N-04730-FM1519 A394812 14/07/2020 Page 5 of 6
2. Declaration (Option 3 of 3)
Instructions: Please select one of the 3 Declaration options, certify for all titles and sign.
C.
discharged by a single entity:
For use where more than one individual and/or entity are listed as the registered holders of the
title(s) and a single titleholder wishes to discharge the entire financial assurance obligation on behalf
i. is in and will maintain compliance with the requirements of section 571(2) of the
Offshore Petroleum and Greenhouse Gas Storage Act 2006; and
ii. discharges the entire obligation on behalf of all registered titleholders in accordance with section
Choose an item. also acknowledge that supplying false or misleading information to a Commonwealth
entity is an offence under the Criminal Code Act 1995, and that providing such false information may
render NOPSEMA’s decisions in accepting environment plans for which this declaration is being made, as
invalid.
EXECUTED by:
Parties signing the declaration
This form has been formatted to allow for the use of electronic signatures. Alternatively the form may be printed and signed in blue
or black ink
1. A company director, authorised officer or individual with the registered titleholders express or
implied authority and on behalf of the titleholder.
Signature Signature
Name Name
Position Position
At [insert place] At [insert place]
On [insert date] On [insert date]
2. A person appointed under power of attorney on behalf of the titleholder
Signature of person who is authorised by Power of Attorney
and who declares that he or she has at the time of execution
of this document no notice of its revocation
Name of person who is authorised by Power of Attorney Provide number or date, details of registration (if any)
At [insert place] On [insert place]
We
We
Reset Form
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
Financial Assurance Declaration
Form
National Offshore Petroleum Safety and Environmental Management Authority N-04730-FM1519 A394812 14/07/2020 Page 6 of 6
Privacy Notice
NOPSEMA collects your personal information so that it can administer the OPGGS Act and associated
regulations as set out above. If you do not provide personal information, NOPSEMA may not be able to
process the declaration.
NOPSEMA will not use or disclose your personal information for any other purpose without your consent,
unless it is required or authorised by law, or if it relates to NOPSEMA’s enforcement activities. Your
personal information may be disclosed to the following organisations, entities or individuals:
individuals who make a request under the Freedom of Information Act 1982
the Australian National Audit Office and other privately-appointed auditor
s
o
ther law enforcement bodies (for example, the police or the Coroner)
NOPSEMA’s legal advisors.
NOPSEMA may occasionally disclose information to overseas recipients in order to discharge its functions,
exercise its powers, or to perform its necessary business activities.
Further information about how you can access, or seek correction to, your personal information is
contained in NOPSEMA’s APP Privacy Policy at www.nopsema.gov.au/privacy
. If you have an enquiry or a
complaint about your privacy, please contact NOPSEMA’s Privacy Contact Officer on 08 6188 8700 or by
email at
privacy@nopsema.gov.au.
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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