This document is an approved form pursuant to s 117J of the Petroleum Act 1984 for determination of the environmental security associated with regulated activities proposed in an Environment Management Plan (EMP). This form may also be used to propose the EMP assessment fee, as required under regulations 6(3) and 6(4) of the Petroleum (Environment) Regulations 2016. The information in this form is being collected for the purpose of assessing your application for a decision on an EMP submitted under regulation 6 of the Petroleum (Environment) Regulations 2016 and the associated EMP Assessment Fee and Environmental Security. An application for an EMP decision is lodged when this Approved Form is complete and sufficient information is provided to enable a proper decision. Please use the checklists below to ensure the Approved Form is complete. Only complete Approved Forms with sufficient information to enable a proper decision will be lodged and subsequently processed. The department will notify you when your Approved Form is lodged.

Approved Form details

Section 1 – Interest Holder Details
For petroleum titles held by multiple interest holders, details must be completed for each interest holder. If insufficient room, please attach information to the Approved Form.
Interest Holder 1	Interest Holder 2	Interest Holder 3	Interest Holder 4
Interest Holder Name
ABN
Postal address
Contact person name
Contact person title
Phone number
Email address for correspondence
Nominated interest holder for all matters related to EMP? If ‘no’ each interest holder must sign Declaration.	☐ Yes ☐ No	☐ Yes ☐ No	☐ Yes ☐ No	☐ Yes ☐ No
Consent to ongoing service of documents for this EMP via the email address above?	☐ Yes ☐ No	☐ Yes ☐ No	☐ Yes ☐ No	☐ Yes ☐ No
☐	ASIC extract attached? Companies must attach a copy of its Australian Securities and Investment Commission (ASIC) current extract listing office holders.
Section 2 – EMP Details
EMP title
EMP date
EMP revision number
Exploration Permit/Operating Licence Number
Section 3 – EMP Assessment Fee
Regulation 6(4) of the Petroleum (Environment) Regulations 2016 requires the prescribed fee accompany an EMP submitted to the Minister for Environment, Parks and Water Security for a decision. The EMP assessment fee is to be calculated in accordance with Schedule 1B of the Petroleum Regulations 2020, using the published Onshore Petroleum Fees and Levies Calculator and the Onshore Petroleum Fees and Levies Calculation Guideline. The completed Onshore Petroleum Fees and Levies Calculator must be submitted with this form.
Please tick one of the below options for the reason you are making this submission:
☐	New Environment Management Plan (EMP) (regulation 6 of the Petroleum (Environment) Regulations 2016)
☐	Revised EMP (regulations 16, 17, 18 or 19 of the Petroleum (Environment) Regulations 2016)
ASSESSMENT FEE: $ (insert calculated assessment fee)
☐	The completed Onshore Petroleum Fees and Levies Calculator is attached.
Section 4 –Environmental Security
Environmental securities for regulated petroleum activities are required under Section 117AP and 117AQ of the Petroleum Act 1984. Regulation 6(3) of the Petroleum (Environment) Regulations 2016 requires an EMP submitted be accompanied by a proposal for the environmental security in connection with that plan, to be approved by the Minister for Environment, Climate Change and Water Security. The environmental security must be calculated for the total of all regulated activities described in the EMP submitted for a decision, using the Onshore Petroleum Environmental Security Calculator and the Onshore Petroleum Environmental Security Calculation Guideline. The completed Onshore Petroleum Environmental Security Calculator must be submitted with this form. A non-compliant environmental security calculation will be returned without determination and a revised environmental security calculation will be required.
Please provide your total environmental security calculation below:
TOTAL ENVIRONMENTAL SECURITY $0.00 (insert total calculated security amount here)
☐	The proposed environmental security has been calculated using the Onshore Petroleum Environmental Security Calculator and the Onshore Petroleum Environmental Security Calculation Guideline.
☐	The proposed environmental security includes all potential remediation and rehabilitation activities required for the regulated activities in the submitted EMP.
☐	The completed Onshore Petroleum Environmental Security Calculator is attached.
Section 5 – Total Fees and Charges
Section 2 – EMP Assessment Fee	$0.00
Section 3 – Environmental Security	$0.00
TOTAL	$0.00
Section 6 – Payment Information
Upon confirmation of the EMP Assessment Fee, an invoice will be issued by the Department of Environment, Parks and Water Security for payment. The invoice will be issued to the interest holder nominated in Section 1 of this form as the interest holder for all matters related to the EMP. Assessment of the EMP will not commence under regulation 6 of the Petroleum (Environment) Regulations 2016 until the EMP Assessment Fee is paid. Further information is provided in the Onshore Petroleum Fees and Levies Calculation Guideline.
Section 117AR(3) allows the Minister for Environment, Climate Change and Water Security to allow an interest holder to provide an amount of security less than would otherwise apply if satisfied that the level of activity or stage in the performance of work does not require the full security. Upon approval of the Environmental Security, an invoice will be issued by the Department of Infrastructure, Tourism and Trade for payment of the Environmental Security for the regulated activities scheduled to occur up to 30 June. Payment of the environmental security is to be made by 31 July of each year. Regulated activities may not commence until the environmental security is paid (section 117AR(2) of the Petroleum Act 1984). Further detail is provided in the Onshore Petroleum Environmental Security Calculation Guideline.
Section 7 – Public Register
In accordance with section 117AZD of the Petroleum Act 1984, the CEO of the Department of Industry, Tourism and Trade must publish on the Agency's website a list of all securities held with sufficient detail to allow members of the public to understand the securities held in relation to each petroleum interest, and the total value of securities held from time to time for all petroleum interests. Information may be supressed if the CEO is satisfied there are grounds of commercial confidentiality. You may apply to have commercially confidential information withheld by application to the CEO of the Department of Industry, Tourism and Trade.
☐	I acknowledge that information about security amounts will be published on the Agency’s website.
☐ Yes ☐ No	I have completed and attached an application to have commercially confidential information withheld.

Section 8 – Declaration
A person with legal authority must sign the declaration. I hereby declare that I: am authorised to make this declaration. confirm that, to the best of my knowledge all information provided, including any attachments, addresses the relevant matters and is true, correct, complete, and does not contain misleading information. am aware that it is an offence under section 107 of the Petroleum Act 1984 to give the administering authority information that I know, or ought to reasonably know, to be false or misleading in a material manner particular. understand that all information supplied as part of this form, including attachments, may be disclosed publically in accordance with section 62A of the Petroleum Act 1984, and consistent with the requirements of the Information Privacy Principles (IPPs) in the Information Act 2002.
Interest Holder 1	Interest Holder 2	Interest Holder 3	Interest Holder 4
Signature
Name (print)
Position
Date
Where and how to submit this form Email your completed Approved Form and associated atatchments to onshoregas.depws@nt.gov.au
Further information All enquiries regarding the completion of this form must be sent to onshoregas.depws@nt.gov.au
End of form

Document approval and review

Document title	Approved Form: Onshore Petroleum Fees and Securities
Contact details	Department of Environment, Parks and Water Security
Approved by	Minster for Environment, Climate Change and Water Security
Date approved	27 June 2023
Document review	Three yearly
TRM number	NTEPA2021/0020-026~0002

Version	Date	Author	Changes made
0.1	June 2023	Petroleum Legislation & Policy	Draft for review
1.0	June 2023	Petroleum Legislation & Policy	FINAL for use