BOEM-0004 OCS renewable energy Lease or Grant Relinquishment Appli

U.S. Department of the Interior OMB Control No.: 1010-0176

Bureau of Ocean Energy Management Expiration Date: xx/xx/xxxx

□ Lease Number: ___________ or □ Grant Number: ___________ BOEM Regional Office: ___________

OUTER CONTINENTAL SHELF (OCS) RENEWABLE ENERGY

LEASE OR GRANT RELINQUISHMENT APPLICATION

The owner(s) of one hundred percent (100%) of the lease or grant interest does (do) hereby release, relinquish and forever quitclaim all of its (their) right, title and interest in and to the renewable energy lease or grant, or subdivision thereof, described in Exhibit “A” attached hereto and made a part hereof.

This relinquishment is effective on the date the Bureau of Ocean Energy Management approves the relinquishment application, subject to the provisions of 30 CFR 585.435. Lessee(s) or grantee(s) agree to comply fully with the decommission requirements of 30 CFR Part 585, Subpart I.

This relinquishment application may be executed in any number of counterparts, each of which is deemed an original instrument, but all of which together constitute but one and the same application, provided however, this application and any other counterpart hereof, is executed by all of the parties, and will not be approved by the Bureau of Ocean Energy Management unless all counterparts are filed simultaneously.

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.

Insert the following information for each Lessee or Grantee

______________________ __________________________

Company Name Company Name

Company Number: __________ Company Number: ______________

By:________________________ By:__________________________

Name: Name:

Title: Title:

__________________________ __________________________

Telephone number Telephone number

__________________________ __________________________

E-mail address E-mail address

_________________________ __________________________

Fax number Fax number

___________________________ _____________________________ Execution Date Execution Date

For BOEM Use only – Do Not Type Below This Line

This Relinquishment has been filed as of the date stamped on this document

and approved by the Bureau of Ocean Energy Management on the date below.

By__________________________________ ______________________________________________

Authorized Official for BOEM Title Approval Date

Attach Notary Acknowledgement (not mandatory)

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 Federal OCS. Responses are mandatory (43 U.S.C. 1337).  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 1 hour 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-0004 (mo/year) Previous Editions are Obsolete PAGE 1 OF 3

EXHIBIT “A”

OUTER CONTINENTAL SHELF (OCS)

RENEWABLE ENERGY LEASE OR GRANT

RELINQUISHMENT

□ Lease Number: ____________

or

□ ROW Grant Number: ____________

or

□ RUE Grant Number: ____________

Name of Facility: _____________________________

This Relinquishment is made with respect to the following described block(s) and/or aliquot part(s) of the referenced lease or grant:

Area Name or Block Subdivision or Aliquot Part

Protraction Diagram (If entire block, enter “All”)

___________________ ________ ________________________

___________________ ________ ________________________

___________________ ________ ________________________

___________________ ________ ________________________

___________________ ________ ________________________

___________________ ________ ________________________

___________________ ________ ________________________

___________________ ________ ________________________

___________________ ________ ________________________

___________________ ________ ________________________

___________________ ________ ________________________

___________________ ________ ________________________

___________________ ________ ________________________

___________________ ________ ________________________

___________________ ________ ________________________

Form BOEM-0004 (mo/year) Previous Editions are Obsolete PAGE 2 OF 3

INSTRUCTIONS FOR

RENEWABLE ENERGY LEASE OR GRANT

RELINQUISHMENT APPLICATION

In order to relinquish a lease or grant, or an officially designated subdivision thereof, you must file one paper copy and one electronic copy of a relinquishment application with BOEM.

1. The relinquishment application must be typed.

2. Describe the block(s) and/or officially designated subdivision(s) (in aliquot parts not less than 1/16 of the block) being relinquished, including the OCS lease number and name of facility, if any, in Exhibit “A.”

3. Enter names of owners (lessees or grantees) of one hundred percent (100%) of the interest in the lease or grant or officially designated subdivision being relinquished. The company number must be entered next to the name of each lessee or grantee. The name, title, and signature of your authorizing official must match exactly the name, title, and signature in BOEM qualification records.

4. Do not include or request an effective date. The relinquishment is effective on the date the relinquishment application is approved by the BOEM.

5. This form may be duplicated by means of word processing software, but any duplicate that differs from the approved form will be deemed to include any omitted language as if it were the original form.

6. Relinquishments must be filed in duplicate (one paper copy and one electronic copy). If relinquishment of multiple leases or grants is intended in the same application, BOEM must receive one paper and one electronic copy for each separate lease or officially designated subdivision being relinquished.

Form BOEM-0004 (mo/year) Previous Editions are Obsolete PAGE 3 OF 3