Carbon Dioxide Storage Facility Cash Financial Assurance Instrument

Carbon Dioxide Storage Facility Cash Financial Assurance Instrument North Dakota Department of Mineral Resources S.F.N 62586 (12 to 2024)

Field: Account Number (if applicable)

Read instructions on page 2 before filling out form. Please submit the original report.

Field: N.D.I.C Instrument Number

Field: Storage Facility Operator

Field: Telephone Number

Field: Address

Field: City

Field: State

Field: Zip Code

The storage facility operator proposes to set up financial assurance in the amount of (select only one):

Checkbox option: Cash Bond $

Checkbox option: Escrow Account $

Checkbox option: Trust Fund $

Checkbox option: Other Approved Method: $

If other, please describe:

For the following carbon dioxide storage facility:

Field: Carbon Dioxide Storage Facility Name and Number

Field: Northstar Facility Number

Field: N.D.I.C Order Number

This financial assurance covers the following costs, pursuant to N.D.A.C § 43-05-01-09.1(b) for the storage facility listed above:

Checkbox option: Corrective Action $

Checkbox option: Injection Well Plugging $

Checkbox option: Post-injection Site Care and Facility Closure $

Checkbox option: Emergency and Remedial Response $

I hereby swear or affirm that the information provided is true, complete and correct as determined from all available records and that the financial instrument being provided complies with N.D.C.C Chapter 38 to 22, N.D.A.C § 43-02-03-15, N.D.A.C § 43-05-01-09.1, and Industrial Commission orders.

Field: Signature

Field: Printed Name

Field: Title

Field: State of

Field: County of

Signed and sworn to (or affirmed) before me this

Field: Date

Field: Name of Individual Making Statement

Field: Affix Notary Stamp

Field: Signature of Notary Public or Other Authorized Officer

Field: Commission Expiration Date

1. In order to file a cash financial assurance instrument, you must first contact the Department of Mineral Resources, Oil and Gas Division.

2. Please refer to Section 43-02-03-15 and Section 43-05-01-09.1 of the North Dakota Administrative Code regarding financial instruments for carbon dioxide storage facilities.

3. Name of applicant shall be the name of the operator and shall be the same as reported on the Organization Report - Form 2 (S.F.N 57444).

4. The storage facility name and number, Northstar facility number, and N.D.I.C Order number shall coincide with the official records on file with the Department.

5. For escrow accounts and trust funds, the form must be accompanied by the executed agreement, including documentation to show that initial funds as required by the Department have been met.

6. The original of this report shall be filed with the Department of Mineral Resources, Oil and Gas Division, 600 E Boulevard Ave, Dept 474, Bismarck N.D 58505 to 0614.