Form MO780-1778 "Oil and Gas Well Financial Assurance Instrument Certification - Geological Survey Program" - Missouri

What Is Form MO780-1778?

This is a legal form that was released by the Missouri Department of Natural Resources - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2018;
  • The latest edition provided by the Missouri Department of Natural Resources;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MO780-1778 by clicking the link below or browse more documents and templates provided by the Missouri Department of Natural Resources.

ADVERTISEMENT
ADVERTISEMENT

Download Form MO780-1778 "Oil and Gas Well Financial Assurance Instrument Certification - Geological Survey Program" - Missouri

Download PDF

Fill PDF online

Rate (4.6 / 5) 91 votes
MISSOURI DEPARTMENT OF NATURAL RESOURCES
GEOLOGICAL SURVEY PROGRAM
OIL AND GAS WELL FINANCIAL ASSURANCE INSTRUMENT CERTIFICATION
OBLIGOR (WELL OWNER/OPERATOR) INFORMATION
NAME OF COMPANY, ORGANIZATION, OR INDIVIDUAL THAT DRILLS, MAINTAINS, OPERATES, OR CONTROLS OIL AND GAS WELLS IN MISSOURI
OPERATOR LICENSE NUMBER
MAILING ADDRESS
CITY
STATE
ZIP CODE
PRIMARY CONTACT NAME
TITLE
PRIMARY PHONE NUMBER WITH
EMAIL ADDRESS
AREA CODE
FINANCIAL INSTITUTION INFORMATION (TO BE COMPLETED BY THE INSTITUTION ISSUING THE FINANCIAL ASSURANCE
INSTRUMENT (FAI))
FINANCIAL INSTITUTION NAME
FINANCIAL INSTITUTION MAILING ADDRESS
CITY
STATE
ZIP CODE
CONTACT NAME
TITLE
PRIMARY PHONE NUMBER WITH
EMAIL ADDRESS
AREA CODE
FAI INFORMATION (TO BE COMPLETED BY THE ISSUING INSTITUTION. CONDITIONS AND REQUIREMENTS FOR FAIS ARE
LOCATED ON THE BACK OF THIS FORM.)
Original FAI Submission
Amendment to existing FAI
Certificate of
ISSUED TO
NUMBER
ISSUE DATE
VALUE
AUTOMATICALLY
RENEWABLE
Deposit (CD)
Yes
No
Irrevocable
IRREVOCABLE
NUMBER
ISSUE DATE
MAXIMUM VALUE
Surety Bond (SB)
Yes
No
Irrevocable Letter
STATE OF MISSOURI BENEFICIARY OF LOC
AUTOMATICALLY RENEWABLE
Yes
No
ESCROW ACCOUNT ESTABLISHED TO SECURE THIS LOC
of Credit (LOC)
IF YES, AMOUNT IN ESCROW ACCOUNT $
Yes
No
Yes
No
NUMBER
ISSUE DATE
EXPIRATION DATE
VALUE
FAI OBLIGOR PLEDGE CERTIFICATION
I, the undersigned, certify I am authorized to act as an agent for the submission of this FAI. I confirm the information on this form has been reviewed by me and is true, correct
and complete to the best of my knowledge. I agree to ensure this FAI remains in full force and effect until a letter of release is issued by the state geologist. I understand this
FAI may be forfeited, without my consent, due to noncompliance with the provisions of Chapter 259, RSMo, and the Missouri Code of State Regulations Oil and Gas Council
Rules 10 CSR 50. I have read and agree to the conditions and requirements on the back of this form. I hereby irrevocably pledge the above described FAI to secure the
obligor’s performance bond(s).
OBLIGOR SIGNATURE (AUTHORIZED AGENT)
OBLIGOR NAME (PRINT)
TITLE
NOTARY PUBLIC EMBOSSER OR RUBBER STAMP
SUBSCRIBED AND SWORN BEFORE ME, ON THIS
SEAL
DAY OF
IN THE YEAR
STATE
COUNTY
MY COMMISSION EXPIRES
NOTARY PUBLIC SIGNATURE
NOTARY PUBLIC NAME (Print)
FAI FINANCIAL INSTITUTION PLEDGE CERTIFICATION
I, the undersigned, certify I am authorized to act as an agent for the financial institution issuing this FAI. I certify the FAI and financial institution information on this form is
accurate. I agree to ensure this FAI remains in full force and effect until a letter of release is issued by the state geologist. I have read and agree to the conditions and
requirements on the back of this form.
AUTHORIZED AGENT SIGNATURE
AUTHORIZED AGENT NAME (PRINT)
TITLE
NOTARY PUBLIC EMBOSSER OR RUBBER STAMP
SUBSCRIBED AND SWORN BEFORE ME, ON THIS
SEAL
DAY OF
IN THE YEAR
STATE
COUNTY
MY COMMISSION EXPIRES
NOTARY PUBLIC SIGNATURE
NOTARY PUBLIC NAME (PRINT)
FOR OFFICE USE ONLY
APPROVED BY
DATE
MO 780-1778 (03-18)
SEND ORIGINAL COMPLETED FORM AND ORIGINAL FINANCIAL ASSURANCE INSTRUMENT TO: MISSOURI DEPARTMENT OF NATURAL RESOURCES,
MISSOURI GEOLOGICAL SURVEY, GEOLOGICAL SURVEY PROGRAM, PO BOX 250, ROLLA, MO 65402
PHONE: 573-368-2100 FAX: 573-368-2111 EMAIL:
oilandgas@dnr.mo.gov
MISSOURI DEPARTMENT OF NATURAL RESOURCES
GEOLOGICAL SURVEY PROGRAM
OIL AND GAS WELL FINANCIAL ASSURANCE INSTRUMENT CERTIFICATION
OBLIGOR (WELL OWNER/OPERATOR) INFORMATION
NAME OF COMPANY, ORGANIZATION, OR INDIVIDUAL THAT DRILLS, MAINTAINS, OPERATES, OR CONTROLS OIL AND GAS WELLS IN MISSOURI
OPERATOR LICENSE NUMBER
MAILING ADDRESS
CITY
STATE
ZIP CODE
PRIMARY CONTACT NAME
TITLE
PRIMARY PHONE NUMBER WITH
EMAIL ADDRESS
AREA CODE
FINANCIAL INSTITUTION INFORMATION (TO BE COMPLETED BY THE INSTITUTION ISSUING THE FINANCIAL ASSURANCE
INSTRUMENT (FAI))
FINANCIAL INSTITUTION NAME
FINANCIAL INSTITUTION MAILING ADDRESS
CITY
STATE
ZIP CODE
CONTACT NAME
TITLE
PRIMARY PHONE NUMBER WITH
EMAIL ADDRESS
AREA CODE
FAI INFORMATION (TO BE COMPLETED BY THE ISSUING INSTITUTION. CONDITIONS AND REQUIREMENTS FOR FAIS ARE
LOCATED ON THE BACK OF THIS FORM.)
Original FAI Submission
Amendment to existing FAI
Certificate of
ISSUED TO
NUMBER
ISSUE DATE
VALUE
AUTOMATICALLY
RENEWABLE
Deposit (CD)
Yes
No
Irrevocable
IRREVOCABLE
NUMBER
ISSUE DATE
MAXIMUM VALUE
Surety Bond (SB)
Yes
No
Irrevocable Letter
STATE OF MISSOURI BENEFICIARY OF LOC
AUTOMATICALLY RENEWABLE
Yes
No
ESCROW ACCOUNT ESTABLISHED TO SECURE THIS LOC
of Credit (LOC)
IF YES, AMOUNT IN ESCROW ACCOUNT $
Yes
No
Yes
No
NUMBER
ISSUE DATE
EXPIRATION DATE
VALUE
FAI OBLIGOR PLEDGE CERTIFICATION
I, the undersigned, certify I am authorized to act as an agent for the submission of this FAI. I confirm the information on this form has been reviewed by me and is true, correct
and complete to the best of my knowledge. I agree to ensure this FAI remains in full force and effect until a letter of release is issued by the state geologist. I understand this
FAI may be forfeited, without my consent, due to noncompliance with the provisions of Chapter 259, RSMo, and the Missouri Code of State Regulations Oil and Gas Council
Rules 10 CSR 50. I have read and agree to the conditions and requirements on the back of this form. I hereby irrevocably pledge the above described FAI to secure the
obligor’s performance bond(s).
OBLIGOR SIGNATURE (AUTHORIZED AGENT)
OBLIGOR NAME (PRINT)
TITLE
NOTARY PUBLIC EMBOSSER OR RUBBER STAMP
SUBSCRIBED AND SWORN BEFORE ME, ON THIS
SEAL
DAY OF
IN THE YEAR
STATE
COUNTY
MY COMMISSION EXPIRES
NOTARY PUBLIC SIGNATURE
NOTARY PUBLIC NAME (Print)
FAI FINANCIAL INSTITUTION PLEDGE CERTIFICATION
I, the undersigned, certify I am authorized to act as an agent for the financial institution issuing this FAI. I certify the FAI and financial institution information on this form is
accurate. I agree to ensure this FAI remains in full force and effect until a letter of release is issued by the state geologist. I have read and agree to the conditions and
requirements on the back of this form.
AUTHORIZED AGENT SIGNATURE
AUTHORIZED AGENT NAME (PRINT)
TITLE
NOTARY PUBLIC EMBOSSER OR RUBBER STAMP
SUBSCRIBED AND SWORN BEFORE ME, ON THIS
SEAL
DAY OF
IN THE YEAR
STATE
COUNTY
MY COMMISSION EXPIRES
NOTARY PUBLIC SIGNATURE
NOTARY PUBLIC NAME (PRINT)
FOR OFFICE USE ONLY
APPROVED BY
DATE
MO 780-1778 (03-18)
SEND ORIGINAL COMPLETED FORM AND ORIGINAL FINANCIAL ASSURANCE INSTRUMENT TO: MISSOURI DEPARTMENT OF NATURAL RESOURCES,
MISSOURI GEOLOGICAL SURVEY, GEOLOGICAL SURVEY PROGRAM, PO BOX 250, ROLLA, MO 65402
PHONE: 573-368-2100 FAX: 573-368-2111 EMAIL:
oilandgas@dnr.mo.gov
FOR OFFICE USE ONLY (APPROVAL FOR RELEASE OF FAI – RELEASE MUST BE ACCOMPANIED BY A LETTER FROM THE
STATE OF MISSOURI)
The obligor of this FAI has met the requirements of Chapter 259 RSMo. and the Missouri Code of State Regulations Oil and Gas Council Rules 10 CSR
50, thereby, the FAI and the amount identified on the front of this form is released per their request.
AUTHORITY TO RELEASE THIS FAI IS HEREBY GRANTED, THIS
APPROVED BY
DAY OF
YEAR
CERTIFICATE OF DEPOSIT PLEDGE CONDITIONS AND REQUIREMENTS
 A paper CD, receipt or certificate, time deposit, etc., must accompany this form.
 The pledged amount of the CD shall secure obligor’s personal performance bond according to Chapter 259 RSMo, and the
Missouri Code of State Regulations Oil and Gas Rule 10 CSR 50-2.020.
 The CD must be automatically renewable.
 The pledged amount of the CD shall not be released or negotiated until the obligor has met full compliance with the Missouri Code
of State Regulations Oil and Gas Council Rule 10 CSR 50-2.020, has plugged the well(s) in accordance with 10 CSR 50-2.060 and
the CD is released by the state of Missouri.
 The financial institution shall place a hold on the CD until a release from this pledge is received in writing by the state of Missouri.
Under no circumstances shall the pledged amount of the CD be released to the owner without a letter of release from the state of
Missouri and a copy of this bond with the foregoing “release” portion signed.
 The financial institution must be protected by the Federal Deposit Insurance Corporation (FDIC).
 The financial institution acknowledges the assignment and pledge of the aforesaid CD to the state of Missouri and agrees to record
the assignment on the back of the CD and/or on its books. Further, the financial institution acknowledges and agrees that it shall
hold the monies represented by the CD as a custodian and agent for the state of Missouri.
 The financial institution must provide information on the aforesaid CD to the state of Missouri upon written request.
 The financial institution must honor upon receipt all demands for payment by and make payment to the state of Missouri within thirty
(30) days of receipt of the demand.
 The interest derived from the CD shall remain the obligor’s and may be paid out as the obligor and financial institution agree. The
state of Missouri may only redeem the pledged amount of the CD.
IRREVOCABLE SURETY BOND CONDITIONS AND REQUIREMENTS
 Original surety bond must accompany this form.
 The pledged amount of the irrevocable surety bond shall secure obligor’s personal performance bond according to Chapter 259
RSMo, and the Missouri Code of State Regulations Oil and Gas Council Rule 10 CSR 50-2.020.
 Only irrevocable surety bonds are acceptable.
 The cancellation of this irrevocable surety bond must be in accordance with the Missouri Code of State Regulations Oil and Gas
Council Rule 10 CSR 50-2.020. Cancellation will not be effective without the approval of the state geologist.
IRREVOCABLE LETTER OF CREDIT CONDITIONS AND REQUIREMENTS
 Original irrevocable letter of credit (LOC) must accompany this form.
 The pledged amount of the irrevocable letter of credit shall secure obligor’s personal performance bond according to Chapter 259
RSMo, and the Missouri Code of State Regulations Oil and Gas Council Rule 10 CSR 50-2.020.
 A complete explanation and all information or documents needed to draw upon this letter of credit must accompany this form. The
LOC must provide for draws to be made on the LOC by U.S. Postal Service certified mail.
 The beneficiary of the irrevocable letter of credit shall be the state of Missouri.
 The LOC shall be governed by Missouri law. The Uniform Customs and Practice for Documentary Credits, fixed by the International
Chamber of Commerce, shall not apply.
 This irrevocable letter of credit shall be forfeited and shall be collected by the state geologist if not replaced by other suitable bond or
irrevocable letter of credit at least 30 days before its expiration date.
 If not a Missouri bank, the Oil and Gas Confirmation of Out of State Irrevocable Letter of Credit form (780-1136) must be submitted.
For questions or additional information, contact the Missouri Geological Survey at 573-368-2143.
MO 780-1778 (03-18)
SEND ORIGINAL COMPLETED FORM AND ORIGINAL FINANCIAL ASSURANCE INSTRUMENT TO: MISSOURI DEPARTMENT OF NATURAL RESOURCES,
MISSOURI GEOLOGICAL SURVEY, GEOLOGICAL SURVEY PROGRAM, PO BOX 250, ROLLA, MO 65402
PHONE: 573-368-2100 FAX: 573-368-2111 EMAIL:
oilandgas@dnr.mo.gov
Page of 2