This document is an approved form pursuant to s 117J of the Petroleum Act 1984, for determination of the annual environmental security for in force Environment Management Plans (EMPs). In accordance with Part VC Division 2 of the Petroleum Act 1984, interest holders are required to submit the environmental security amount relative to the yearly works program and approved payment schedule. This document may also be used to vary an approved environmental security amount. The information in this form is being collected for the purpose of assessing the environmental security amount payable. Section 117AR(3) of the Petroleum Act 1984 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. For annual environmental security determinations, the Annual Return should be submitted no later than 1 June each year. The environmental security payable for the forthcoming financial year, as determined by the Minister for Environment, Parks and Water Security, must be paid prior to commencing the regulated activities and no later than 31 July. For variation of an existing environmental security, a period of no less than 30 days should be allowed to make a determination, and any associated commencement of new regulated activities must not commence prior to the environmental security being approved and paid.

Annual Return details

Section 1 – Approved Environment Management Plan Details
EMP title
Unique EMP ID
EMP approval date
Return Year/Period
Exploration Permit/Operating Licence Number
Section 2 – 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 Annual Return.
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
Section 3 – Reason for Submission
Please tick one of the below options for the reason you are making this submission (more than one may apply).
☐	Annual security calculation
☐	There is an increase in the likely maximum amount of disturbance
☐	There is a change in the activity that may result in an increase to the current environmental security determination
☐	A notice was issued directing the interest holder to resubmit an environmental security for determination
☐	New environmental security decision – please provide details of the reason below (e.g. partial surrender approved, a change in operations which may result in a decrease in environmental security, etc)
Section 4 – Security Required – Completed and Proposed Works
The total environmental security for an approved EMP is determined at the time of the EMP approval. Annual security payments are based on annual work programs approved in the EMP and variations to an approved environmental security are based on the proposed variation to the regulated activity. This section determines the security required based on activities completed and activities to commence within the forthcoming financial year, should the anticipated work program have changed. The approved method in the Onshore Petroleum Environmental Security Calculation Guideline and the Onshore Petroleum Environmental Security Calculator must be used to calculate the environmental security payable or to be varied or reduced. The final environmental security is determined by the Minister for Environment, Parks and Water Security.
Forthcoming work program financial year: (insert applicable financial year)
Approved security for the forthcoming work program (from EMP approval): $0.00
Previous financial year work program activities completed
List the work program activities that were anticipated to be conducted in the previous financial year (for which a security has been paid):
Security paid for previous financial year (based on the anticipated activities above): $0.00
List the anticipated work program activities from the previous financial year that either were not conducted or were varied:
Security paid for previous financial year of activities that were not conducted or were varied: $0.00
List any activities that were not conducted in the previous financial year, or were varied in the previous financial year, and that are planned to be conducted in the forthcoming financial year.
Value of security for activities not previously conducted, or varied, that will be conducted in the forthcoming financial year: $0.00
Value of security for activities not previously conducted, or varied, that will not be conducted in the forthcoming financial year that should be deducted from the security payable for the forthcoming financial year: $0.00
New proposed work program activities for the forthcoming financial year
List proposed new work program activities for the forthcoming year:
Value of security for new proposed activities for the forthcoming financial year: $0.00
Section 5 – Fees and Charges Summary
Security paid for previous financial year	$0.00
Security paid for previous financial year of activities that were not conducted or were varied	$0.00
Value of security for activities not previously conducted, or varied, that will be conducted in the forthcoming financial year	$0.00
Value of security for activities not previously conducted, or varied, that will not be conducted in the forthcoming financial year that should be deducted from the security payable for the forthcoming financial year	$0.00
Value of security for new proposed activities for the forthcoming financial year	$0.00
Environmental security required for forthcoming financial year:	$0.00

Section 6 – Calculator Check
Interest holders must use the Onshore Petroleum Environmental Security Calculator and the Onshore Petroleum Environmental Security Calculation Guideline to calculate the environmental security amount, and submit the completed Onshore Petroleum Environmental Security Calculator in Microsoft excel format with this form.
☒	The Onshore Petroleum Environmental Security Calculator has been completed and is attached.
Section 7 – Payment Information
Upon approval of the environmental security amount an invoice will be issued by the Department of Industry, Tourism and Trade 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. 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 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 Annual Return 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

Document approval and review

Document title	Annual Return: Onshore Petroleum Environmental Security
Contact details	Department of Environment, Parks and Water Security
Approved by	Minister for Environment, Climate Change and Water Security
Date approved	XX 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	xx June 2023	Petroleum Legislation & Policy	FINAL for use