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 Qualification No. Company Qualification No.

By: ________________________________ By: _________________________________

Signatory Name: Signatory Name:

Signatory Title: Signatory Title:

___________________________________ _____________________________________

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 hereby 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, Bureau of Ocean Energy Management, 45600 Woodland Road, Sterling, Virginia 20166.

Form BOEM-0004 (Month/Year) Previous Editions are Obsolete. PAGE 1 OF 2

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 grant:

Area Name or Subdivision or Aliquot Part

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

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Form BOEM-0004 (Month/Year) Previous Editions are Obsolete. PAGE 2 OF 2