U.S. Department of the Interior OMB Control No.: 1010-0176
Bureau of Ocean Energy Management Expiration Date: xx/xx/xxxx
Lease No.
OUTER CONTINENTAL SHELF (OCS) RENEWABLE ENERGY
New Lease No. (BOEM Use Only)
_____________________________
BOEM Regional Office
This assignment is made with respect to the block(s) and/or aliquot part(s) described in Exhibit “A” attached hereto and made a part hereof.
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
Company Number: _____
Company Name: _____________________
Assignee(s): Percentage Interest Received
Company Number: _____
Company Name: _____________________
□ Exhibit “B,” which sets forth other provisions between Assignor(s) and Assignee(s), is attached to and made a part of this assignment.
This Assignment of Record Title Interest has been filed as of the date stamped on this document and hereby approved by the Bureau of Ocean Energy Management on the date below.
By__________________________________ ______________________________________________
Authorized Official for BOEM 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. The BOEM uses the information to track ownership of leases in the OCS. Responses are required to obtain or retain a benefit. Release of such data and information is covered under 30 CFR 585.113. 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 Information Collection Clearance Officer, Mail Stop HM-3127, Bureau of Ocean Energy Management, 381 Elden Street, Herndon, VA 20170.
Form BOEM-0003 (mo/year) Previous Editions are Obsolete PAGE 1 OF 3
Assignor(s) certifies it is the owner of the interest in the above-described lease that is hereby assigned to the Assignee(s) specified above.
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 interest assignment by including this term in its contracts and transactions.
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.
Assignee’s execution of this assignment constitutes acceptance of all applicable terms, conditions, stipulations and restrictions pertaining to the lease described herein. Applicable terms and conditions include, but are not limited to, an obligation to conduct all operations on the leasehold in accordance with the terms and conditions of the lease, to restore the leased lands upon completion of any operations as described in the lease, and to furnish and maintain bond(s) pursuant to regulations at 30 CFR Part 585. This assignment is subject to the Outer Continental Shelf Lands Act of August 7, 1953, 43 U.S.C. 1331 et seq., as amended (the “Act”), and Assignee(s) is subject to, and shall 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 Ocean Energy Management is governed by 30 CFR Part 585.
This Assignment of Interest will be made effective between the parties hereto as of _______________, upon approval by the Bureau of Ocean Energy Management, 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 shall 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.
I certify that the statements made herein by the undersigned are true, complete and correct to the best of my knowledge and belief and are made in good faith.
Title 18 U.S.C. 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:
Company Name: Company Name:
___________________________ _____________________________ Execution Date Execution Date
ASSIGNEE ASSIGNEE
By:________________________ By:__________________________
Name: Name:
Title: Title:
Company Name: Company Name:
___________________________ _____________________________ Execution Date Execution Date
Attach Notary Acknowledgement (not mandatory)
Form BOEM-0003 (mo/year) Previous Editions are Obsolete PAGE 2 OF 3
EXHIBIT “A”
OUTER CONTINENTAL SHELF (OCS)
RENEWABLE ENERGY LEASE
ASSIGNMENT OF INTEREST
The Assignment is made with respect to the following described block(s) and/or aliquot part(s) of the lease:
Area Name or Block Subdivision or Aliquot Part
Protraction Diagram (If entire block, enter “All”)
___________________ ________ ________________________
___________________ ________ ________________________
___________________ ________ ________________________
___________________ ________ ________________________
___________________ ________ ________________________
___________________ ________ ________________________
___________________ ________ ________________________
___________________ ________ ________________________
___________________ ________ ________________________
___________________ ________ ________________________
___________________ ________ ________________________
___________________ ________ ________________________
___________________ ________ ________________________
___________________ ________ ________________________
___________________ ________ ________________________
Form BOEM-0003 (mo/year) Previous Editions are Obsolete PAGE 3 OF 3
| File Type | application/msword |
| File Title | UNITED STATES |
| Last Modified By | Bajusz, Arlene |
| File Modified | 2012-02-23 |
| File Created | 2012-02-08 |