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Previous Editions are Obsolete.
U.S. Department of the Interior
Bureau of Ocean Energy Management
OMB Control No.: 1010-0006
Expiration Date 1/31/2023
RELINQUISHMENT OF FEDERAL OCS OIL AND GAS LEASE
Legal description of the lease/officially designated subdivision being relinquished:
The owner(s) of one hundred percent (100%) of the record title interest does (do) hereby release, relinquish and
forever quitclaim all of its (their) right, title and interest in and to the oil and gas lease, or subdivision thereof,
described above.
This relinquishment is effective as of the date it is filed with the appropriate OCS office of the Bureau of Ocean
Energy Management, subject
to the provisions of 30 CFR 556, Subpart K, Termination of Leases.
This instrument may be executed in any number of counterparts, each of which must be deemed an original
instrument, but all of which together must constitute but one and the same instrument provided. However, this
instrument and any other counterpart hereof, will not be binding unless and until executed by all of the parties, and
will not be accepted by the Bureau of Ocean Energy Management unless all counterparts are filed simultaneously.
Title 18 U.S.C. Sec. 1001 makes it a crime for any person knowingly and willfully to make to any Department or
agency of the United States any false, fictitious or fraudulent statements or representations as to any matter within
its jurisdiction.
Insert name and Company number of each Lessee
By: _______________________________________
Name: ___________________________________
Paperwork Reduction Act of 1995 (PRA) Statement: The PRA (44 U.S.C. 3501 et seq.) requires us to inform you that we collect this information to use in the
ad
judication process involved in leasing and lease operations. BOEM uses the information to track ownership of leases in the Federal OCS. Responses are
mandatory (43 U.S.C. 1334). Proprietary data are covered under section 26 of the OCSLA, 30 CFR 556.10 and in accordance with regulations in 30 CFR parts
550, 551, and 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 OMB Control Number. Public reporting burden of this form is estimated to average 1 hour per response, including the time for reviewing instructions,
gathering and maintaining data, and completing and reviewing the form. 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.
______________
Lease Number
BOEM-0152 (January 2020)
Previous Editions are Obsolete.
Title: ____________________________________
By: _______________________________________
Name: ___________________________________
Title: ____________________________________
Execution Date
LESSEE:
LESSEE:
Execution Date
Attach Notary Acknowledgment (not mandatory)
