Form BSEE-0149 Assignment of Federal OCS Pipeline Right-of-Way Grant

U. S. Department of the Interior OMB Control Number: 1014-0016

Bureau of Safety and Environmental Enforcement (BSEE) OMB Approval Expires: xx/xx/xxxx

ASSIGNMENT OF FEDERAL OCS PIPELINE RIGHT-OF-WAY GRANT

Part A: Assignment

Legal description of the Pipeline Right-of-Way Grant being assigned (Please include Segment Number):

Assignor(s) does hereby sell, assign, transfer, and convey unto Assignee(s) the following undivided right, title and interest:

Insert name and Company number of each Assignor and Assignee.

Assignor(s): Percentage Interest Conveyed

Assignee(s): Percentage Interest Received

 Exhibit “A,” which sets forth other provisions between Assignor(s) and Assignee(s), is attached to and made a part of this assignment

For BSEE Use only – Do Not Type Below This Line

UNITED STATES OF AMERICA

This Assignment of Federal OCS Pipeline Right-of-Way Grant has been filed as of the date stamped on this document and hereby approved by the Bureau of Safety and Environmental Enforcement on the date below.

By__________________________________ _______________________________________________

Authorized Official for BSEE Title Approval Date

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 adjudication process involved in leasing and lease operations. BSEE uses the information to track ownership of leases in the Federal OCS. Responses are required to obtain or retain a benefit (43 U.S.C. 1334).  Proprietary data are covered under 30 CFR 250.197.  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 30 minutes per response, including the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form.  Direct comments regarding the burden estimate, or any other aspect of this form, to the BSEE Information Collection Clearance Officer, 381 Elden Street, Herndon, VA 20170.

BSEE FORM BSEE-0149 (Mo/Year – Supersedes all previous versions of this form which may not be used). Page 1 of 2

Part B – Certification and Acceptance

1. Assignor(s) certifies it is the owner of the interest in the above-described Federal OCS Pipeline Right-of-Way Grant that is hereby assigned to the Assignee(s) specified above.

2. DEBARMENT COMPLIANCE: Assignee shall comply with the Department of the Interior’s nonprocurement debarment and suspension regulations as required by Subpart B of 2 CFR Part 1400 and shall communicate the requirement to comply with these regulations to persons with whom it does business related to this record title interest assignment by including this term in its contracts and transactions.

3. Equal Opportunity and Affirmative Action compliance certification: Assignor(s) and Assignee(s) certify that they are in full compliance with Equal Opportunity Executive Order 11246, as amended, and the implementing regulations at 41 CFR 60-01 – Obligations of Contractors and Subcontractors; and 41 CFR 60-2 – Affirmative Action Programs. These requirements are for the purpose of preventing discrimination against persons on the basis of race, color, religion, sex, or national origin. These regulations have specific performance requirements.

4. Assignee’s execution of this assignment constitutes acceptance of all applicable terms, conditions, stipulations and restrictions pertaining to the right-of-way grant described herein. Applicable terms and conditions include, but are not limited to, an obligation to conduct all operations in accordance with 30 CFR 250 and 550, Subpart J and to furnish and maintain such bond(s) as may be required by the Lessor pursuant to regulations at 30 CFR 556. This assignment is subject to the Outer Continental Shelf Lands Act of August 7, 1953, 67 Stat. 462; 43 U.S.C. 1331 et seq., as amended (the “Act”), and Assignee(s) is subject to, and must fully comply with, all applicable regulations now or to be issued under the Act. Notwithstanding any agreement between the Assignor(s) and Assignee(s), the parties’ liability to the Bureau of Safety and Environmental Enforcement is governed by 30 CFR 250.

This Assignment of Federal OCS Pipeline Right-of-Way Grant will be made effective between the parties hereto as of _______________, upon approval by the Bureau of Safety and Environmental Enforcement, United States Department of the Interior.

This instrument may be executed in any number of counterparts, each of which will be deemed an original instrument, but all of which together will 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 Safety and Environmental Enforcement unless all counterparts are filed simultaneously.

I certify that the statements made herein by the undersigned are true, complete, correct to the best of my knowledge and belief, and are made in good faith.

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.

ASSIGNOR ASSIGNOR

By:________________________ By:__________________________

Name: Name:

Title: Title:

___________________________ _____________________________ Execution Date Execution Date

ASSIGNEE ASSIGNEE

By:________________________ By:__________________________

Name: Name:

Title: Title:

___________________________ _____________________________ Execution Date Execution Date

Attach Notary Acknowledgement (not mandatory)

BSEE FORM BSEE-0149 (Mo/Year – Supersedes all previous versions of this form which may not be used). Page 2 of 2