BOEM-0004 OCS Renewable Energy Lease or Grant Relinquishment Appli

U.S. Department of the Interior
Bureau of Ocean Energy Management
□ Lease Number: ___________

OMB Control No.: 1010-0176
Expiration Date: xx\xx\202x

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 Qualification No.

Company Name:
Company Qualification No.

By: ________________________________
Signatory Name:
Signatory Title:

By: _________________________________
Signatory Name:
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.

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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
Protraction Diagram

Block

Subdivision or Aliquot Part
(If entire block, enter “All”)

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Form BOEM-0004 (Month Year) Previous Editions are Obsolete.

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