HomeMy WebLinkAbout909484Form 3000-3
(October 1992)
UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
ASSIGNMENT OF RECORD TITLE INTEREST IN A
LEASE FOR OIL AND GAS OR GEOTHERMAL RESOURCES
Mineral Leasing Act of 1920 (30 U.S.C. 181 et seq.)
Act for Acquired Lands of 1947 (30 U.S.C. 351-359)
Geothermal Steam Act of 1970 (30 U.S.C. 1001-1025)
Department of the Interior Appropriations Act, Fiscal Year 1981 (42 U.S.C. 6508)
FORM APPROVED
OMB NO. 1004-0034
Expires: July 31, 1995
Lease Serial No.
WYW - 0322062
Lease effective Date
(Anniversary Date)
New Serial No.
Type or print plainly in ink and sign in ink.
PAB...T A: A.SSIGNMEN. Z,
Barbara Allan Simpson, Trustee ur '±'ne Barbara Allan Simpson 2002
1. Assignee* Trust Dated April 5 2002
Street ' '
City, State, Zi¢ {~de F e rnwo o.d Drive
Morag~a California 94556
* If more than one assignee, check here[_] and list the name(s) mid address(es) of all additional assignees on the rexerse of this form or on a separate attached
sheet of paper.
This record title assignment is for: (Check one) [] Oil and Gas Lease, or [] Geothermal Lease
Interest conveyed: (Check one or both, as appropriate) [] Record Title, ~] Overriding Royalty, payment out of production or other similar
interests or payments
2. This assignment conveys the following interest:
Land l~escription Percent of Interest Percent of
Owned Conveyed Retained Overriding Royalty
Additional space on reverse, if needed. Do not submit documents or agreements other than or Similar Interests
this form; such documents or agreements shall only be referenced herein. Reserved Previously
reserved
or conveyed
a b c d E f
Township 23 North, Range 112 West
Section 23 : SE/SE/4
Lincoln County, Wyoming
FOR BLM USE ONLY -DO NOT WRITE BELOW THIS LINE
UNITED STATES OF AMERICA
This assignment is approved solely for administrative purposes. Approval does not warrant that either party to this assignment holds legal or equitable
title to this lease.
[] Assignment approved for above described lands; [] Assignment approved for attached land description
[] Assignment approved for land description indicated on reverse
Assignment approved effective of this I?om.
By
(Authorized Officer)
RECEIVED 6/24/2005 at 10:25 AM
RECEIVING # 909484
BOOK: 589 PAGE: 253
~ JEANNE WAGNER
i::'ri~C01N COUNTY CLERK, KEMM[RER
Part A (Contint,ed): ADDITIONAL SPACE for Names and addresses of additional assignees in Item No. 1, if needed, or for Land Description in Item No. 2, if needed.
00254
PART B: CERTIFICATION AND REQUEST FOR APPROVAL
The Assignor certifies as owner of an interest in the above designated lease that he/she hereby assigns to the above assignee(s) the rights specified above.
Assignee certifies as follows: (a) Assi,~cc is a citizen ot'the United States; an association of such citizens; a municipality; or a corporation organized under the laws
of thc United States or o£any State or territory thcr¢o£. For the assignment o£NPR-A leases, assignee is a citizen, national, or resident alien o£thc United States or
association of such citizens, nationals, resident aliens or private, public or municipal corporations; (b) Assignee is not considered a minor under the
laws of the State in which the lands covered by this assignment are located; (c) Assignee's chargeable interests, direct and indkect, in each public domain and
acquired lands separately in the san~e State, do not exceed 246,080 acres in oil and gas leases (of which up to 200,000 acres may be in oil and gas options), or
300,000 acres in leases in each leasing District in Alaska of which up to 200,000 acres may be in options, if this is an oil and gas lease issued in accordance
with the Mineral Leasing Act of 1920, or 51,200 acres in any one State if this is a geothermal lease; (d) All parties holding an interest in the assignment are
otherwise in compliance with the regulations (43 CFR Group 3100 or 3200) and the authorizing Acts; (e) Assignee is in compliance with reclamation requkements
for all Federal oil and gas lease holdhigs requked by sec. 17(g) of the Mineral Leasing Act; and (f) Assignee is not in violation of sec. 41 of the Mineral Leasing Act.
Assignee's signature to this assignment constitutes acceptance of all applicable terms, conditions, stipulations and restrictions pertaining to the lease described
herein.
For geothermal assignments, aq overriding royalty may not be less than oue-fourth (¼) of one percent of the value of output, nor greater than 50 percent of the rate of royalty
due to the United States when this assignment is added to all previously created overriding royalties (43 CFR 3241).
I certify that the statements made herein by me are true, complete, and correct to the best of my ~knowledge and belief and are ~nade in good faith
.day of , ,-2000;-, effective Executed this ] I day of ,. , :2000- .
June 1, 1999.
Barbara A. Simpson
Name of Assignor as shown on current lease
~// ~~ Barbara Allan Simpson, Trustee
As~.o~ ~ A~si~.ee Of The Barbara Allan Simpson
or Barbara A. or
Attorney Attorney-in-Fact 2002 Trust, Dated April 5, 2002
in-fact
288 Fernwood Drive
(Assignor's Address) By:
Moraga CA 9~556
Trustee
(City) (State) (Zip Code)
Public reporting burden for this form is estimated to average 30 minutes per response, including the time for reviewing instructions, gathering and maintaining data, and
completing and reviewing the form. Direct comments regarding the burden estimate or any other aspect of this form to U.S. Department of the Interior, Bureau of Land
Management, (Alternate) Bureau Clearance Officer, (WO-771), 1849 C Street, N.W. Washington, D.C. 20240, and the Office of Management and Budget, Paperwork
Reduction Project (1004-0034), Washington, D.C. 20503.
Title l 8 U.S.C. Sec. 1001 makes it a crime for any person knowingly and willfully to make to any Department or agency of the United States any false, fictitious or fraudulent
statements or representations as to any matter within its jurisdiction.
STATE OF CALIFORNIA )
,00255
Notary Public (here~ insert name and title of officer) personally appeared
./'~/~,,¢.4'£,,'~ ..~. ~_J ~/.r~,,o,_~ryx2' , personally known to me (or proved to me on the
basis of satisfactory evidence) to be the person whose name is subscribed to the within instrument
and acknowledged to me that ..q/?&' executed the same in,z/,~,r~authorized capacity and that by,W'~-,~.
signature on the instrument the person or the entity upon behalf of which the person acted, executed
the instrument.
WITNESS m/~d and official seal.
Sign atu~j,..Z~~~~ ~ ~~ &/"~ ~) (Seal)
!,,~ EILEENLORRAINEVILCHINSKY~
~ ~;) Notary Public- California
] k~ Contra Costa County