Carbon Dioxide Storage Facility Surety Or Insurance Instrument

Carbon Dioxide Storage Facility Sure or Insurance Instrument North Dakota Department of Mineral Resources S.F.N 6386 (12 to 2024)

Field: Financial Instrument Number (if applicable)

The financial responsibility form and the notary page shall be printed or copied front to back before signing and notarizing. Please read instructions before filling out form. Please submit the original.

Field: N.D.I.C Instrument Number

Field: Name of Principal of This Instrument

Field: Financial Instrument Company Name

Field: The State the Financial Instrument Company is Incorporated in

Field: Amount Principal and Instrument Company is Indebted to the State of North Dakota

In consideration of allowing the principal to operate a carbon dioxide storage facility, principal and instrument company, both authorized to do business in North Dakota, are indebted to the State of North Dakota in the sum, as specified above, for which payment principal and surety bind ourselves and our legal representatives and successors, jointly and severally.

The condition of this obligation is that the principal desires to inject carbon dioxide into an approved storage facility for geologic storage within the State of North Dakota and this bond is issued by N.D.C.C.  38-20-23 and the North Dakota Industrial Commission's administrative rules to provide financial assurance that money is available to fund the storage operator's obligations. If the principal, in its operations, fully complies with N.D.C.C. Chapter 38 to 22 and the Industrial Commission's orders and administrative rules, together with all amendments to Chapter 38 to 22 and the administrative rules, then this obligation is void, otherwise it remains in full force and effect.

The instrument shall remain in full force and effect until such time as the principal has fully complied with all requirements set forth by the Commission and the Commission authorizes the release of the instrument, or until other financial assurances are in place and approved by the Commission. If the principal does not fully satisfy the Commission's requirements for release of the financial instrument, then the instrument company shall satisfy the remaining requirements or forfeit the face value of the instrument to the Commission. The instrument shall not be terminated, amended, or transferred without prior written approval of the Commission.

North Dakota law governs this instrument.

The Financial Instrument being selected to cover the carbon dioxide storage facility below is (select only one):

Checkbox option: Surety Bond

Checkbox option: Insurance

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: Post-injection Site Care and Facility Closure $

Checkbox option: Injection Well Plugging $

Checkbox option: Emergency and Remedial Response $

Instructions for signatures:

If you are a corporation, use your full corporate name and have a corporate officer sign. If you are a partnership, so state and have at least one general partner sign. If you are an individual doing business under a business name, state your name and your business' name and after your signature state that you are the sole owner. Any other person signing on behalf of the principal or financial instrument company must attach a power of attorney. Insurance companies shall attach certificate of insurance (Acord 25 form).

Field: Name of Principal of This Instrument (See other side for notary)

Field: Telephone Number

Field: Address

Field: City

Field: State

Field: Zip Code

Field: Signature

Field: Printed Name

Field: Title

Field: Name of Surety or Insurer (See other side for notary)

Field: Telephone Number

Field: Address

Field: City

Field: State

Field: Zip Code

Field: Signature

Field: Printed Name

Field: Title

Acknowledgment of Principal

Field: State of

Field: County of

Field: Signed and sworn to (or affirmed) before me this

Field: Date

Field: Name(s) of Individual(s) Making Statement

Field: Affix Notary Stamp

Field: Signature of Notary Public or Other Authorized Officer

Field: Date

Acknowledgment of Surety or Insurer

Field: State of

Field: County of

Field: Signed and sworn to (or affirmed) before me this

Field: Date

Field: Name(s) of Individual(s) Making Statement

Field: Affix Notary Stamp

Field: Signature of Notary Public or Other Authorized Officer

Field: Date

Instructions

1. Please refer to sections 43-02-03-15 and 43-05-01-09.1 of the North Dakota Administrative Code regarding carbon dioxide storage facility bond requirements.

2. Name of principal shall be the name of the operator and shall be the same as reported on the Organization Report - Form 2 (S.F.N 5748).

3. The form and the notary page shall be printed or copied front to back before signing and notarizing.

4. 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.