Self-declaration on implemented NOx-reduction measures

P.O. Box 5250 Majorstuen NO-0303 Oslo Norway

Self-declaration on implemented NOx-reduction measures This self-declaration is used to verify the measure's effect and costs. Information can be attached if needed. For measures that require operation to document the effect of the measure, this operation has to be carried out over 3 or 12 consecutive months with stable operation after the implementation1.This will form the basis for the final investment support granted. By agreement with the NOx Fund the subsequent 3 months period can also be reported provided that this will give a more representative image of the vessel's normal operational situation. For measures with a 3-12 months operational period the support can be paid stepwise as updated reports are submitted. For "dual fuel"-ships the operation in Norwegian waters shall be reported to the Fund for a period of 2 years to ensure that the ship is operated with gas over time. Separate declaration forms has to be filled out for the specification of costs connected to LNG measures on ships and of the operational profile of engines in hybrid motor systems. The NOx Fund reserves the right, when found necessary, to utilise AIS data for the relevant vessel to verify information in the self-declaration regarding the activity level, fuel consumption in traffic eligible for support and pertaining estimated NOx-reductions where this is available and considered as appropriate. Applicant Information Company name (alternatively Norwegian representative)

Organisation number

Postal address

Postal code

City

Contact person

E-mail address

Telephone number

Mobile phone number

Name of ship, rig or production unit

The NOx Fund's reference number (cf. commitment letter) IMO number (callsign if any)

Financial Figures Documented expenses, main items and total costs [NOK]

Copies of all invoices for expenses related to the purchase of the installation. If the costs are dependent of exchange rates, this has to be informed. 1

The verification period for self-declaration of SCR-systems was set to 12 months in January 2014 for vessels that are not operating in regular routes. For vessels with a minimum of 3 months verification period, it is important that the chosen period is representative of the vessel's operation.

Updated 16.03.2015

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Account number for payment of support Name of the bank

Account number

IBAN number (if a non-Norwegian bank is used)

SWIFT code (if a non-Norwegian bank is used)

Information on the applied-for measure – feasibility Type of measure (supplier, number of engines and their size, and other information describing the measure):

Installation finished (date):

Start of regular operation (date):

Description of contracts for operation in waters subject to NOx tax and regular routes:

Prospective supplementing comments to the operating situation and description of operating interruption:

Yearly consumption and emission Consumed fuel before measure (tonnes/year)

Consumed fuel after measure (tonnes/year)

Consumed NOx fuel reduction emission (tonnes/year) before measure (kg/year)

NOx emissions after measure (kg/year)

NOx reduction (kg/year)

Operation subject to NOx tax Operation between installations¹ Total operation subject to NOx tax (operation eligible for support and other operation) 1.

2.

3.

Applies only to offshore service ships. The Environmental Agreement (The Environmental Agreement Concerning Reduction of NOx Emissions for the Period 2011-2017) point 4.1, 2nd paragraph: "When implementing measures on ships, also the effect the measure has on ship operations between permanent installations at sea within Norway’s economic zone may be credited to the reduction obligations in article 3.2, on the condition that such shipping is part of shipping that is in its entirety conducted between Norwegian ports, without docking at a foreign harbour or at permanent installations at sea outside of Norway’s economic zone, i.e. that the emissions are included in the Norwegian emission inventory." Verification of ships/installations with propulsion by LNG (or other alternative energy carrier) is based on reported consumption of LNG and possible diesel or other energy carriers. This ongoing consumption over time must be shown through attachments. Consumption of potential additives that are used for emission purification must also be stated over time in attachments.

Updated 16.03.2015

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Signature from responsible applicant at the enterprise Date:

Name:

Attachments: Receipts of documented expenses. Measurement certificates that show emission factor with and without emission reducing technology in operation. Calculations Photo of the implemented measure if relevant.

Updated 16.03.2015

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