HomeMy WebLinkAbout876145 Forth 3000-3" I '~/' O
(January 1996) UNITED STATES
.. DEPARTMENT OF THE INTERIOR FORM APPROVED
" BUREAU OF LAND MANAGEMENT OMB NO. 1004-0034
Expires: September 30, 1998
ASSIGNMENT OF RECORD TITLE INTEREST IN A Lease Serial No.
LEASE FOR OIL AND GAS OR GEOTHERMAL RESOURCES MASS ASSIGNMENT
Lease Effective Date
Mineral Leasing Act of 1920 (30 U.S.C. 181 et seq.) (Anniversary Date)
Act for Acquired Lands of 1947 (30 U.S.C. 351-359)
Geothermal Steam Act of 1970 (30 U.S.C. 1001-1025) New Serial No.
Department of the Interior Appropriations Act, Fiscal Year 1981 (42 U.S.C. 6508)
Type or print plainly in ink and si~ln in ink.
PART A: ASSIGNMENT
1. Assignee* INTREPID OIL & GAS,LLC
Street 700 17t~ STREET, SUITE 1700
City, State, ZIP Code Denver, CO 80202
*If more than one assignee, check here [] and list the name(s)and address(es) of all additional assignees on the reverse 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 Description Percent of Interest Percent of
Additional space on reverse, if needed. Do not submit documents or agreements other than Owned Conveyed Retained Overriding Royalty
this form; such documents or agreements shall only be referenced herein.
or Similar Interests
Reserved Previously
reserved
or conveyed
a b c d e f
MASS ASSIGNMENT
SEE EXHIBIT 'A' ATTACHED HERETO AND BY THIS
REFERENCE MADE A PART HEREOF.
Assignment is subject to'the terms and conditions of that Letter
Agreement dated January 14, 1997, by and between Mission Oil
Corporation, Emerald Resources, Inc. and Terry W. Donze and is
intended to assign all of the right, title'and interest of Terry W. Donze
to Intrepid Oil & Gas, LLC
.,~....,'_... ~..vllr'..lYy OLEnL
9~L' VLDOTNOT,;WRIqtE BELOW THIS LINE
This assignment is approved solely far adminislrative purposes. Approval does not warrant that either par~y to this a~signment holds legal or
equitable title to this lease.
I [] Assignment approved for above described lands; [] Assignment approved for attached land description
Assignment approved effective [] Assigmnent approved for land description indicated on reverse
' of this form.
Bv
(Authorized Officer) : (TitLe) (Date)
Part A (Contimi'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.
PART B: CERTIFICATION AND REQUEST FOR APPROVAL
1. 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.
2. Assignee certifies as follows: (a) Assignee is a citizen of the United States; an association ofsoch citizens; a municipality; or a corporation organized under the laws o1
the United States or of any State or territory thereof. For the assignment of NPR-A leases, assignee is a citizen, national, or resident alien of the United States or
associations 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 indirect, in each public domain and acquired lands separately in
the same 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 complian.ce with reclamation requirements for ali Federal off and gas holdings as required by
sec. 17(g) of the Mineral Leasing Act; and (f) Assignee is not in violation of sec. 41 of the Mineral Leasing Act.
ss gu~s s~gnature to this assignment constitutes acceptance of all applicable terms, conditions, stipulations and restrictions pertaining to the lease described herein.
For geothermal assignments, an overriding royalty may not be less than one-fourth (1/4) of one percent of the value of output, nor greater than 50 percent of'the rate of
royalty due to the United States when tiffs is added to all previously created overriding royalties (43 CFR 3241).
~ certify that the statements made herein by ~ne are tree, complete, and correct to the best of my knowledge and belief~nd are made insod fai~.
Executed this ,,/~ 4' l~.
-- dayof ,~y-//c-,-~,~,?li~r:2o01 Executed this . ['2~(k.. day0f .~ff~/~ _,2001
Name of Assignor as shown on current lease. Terry W. Donze
' e-"-"'-' , Please type or print INTREPID OIL & GAS, LLC
4048 Simms Street ~3~ a~y ~
(Assignor's Address) ( 'gn ) bert P.J
Wheatridge CO 80033 ~
(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, Bureau Clearance Officer (DW-110), Denver Federal Center, Building 40, P.O. Box 25047 Denver, CO 802254)047 and the Office of Management and
Budget, Paperwork Reduction Project (1004-0034), Washington, D.C. 20503 '
Title 18 U.S.C. See. 1001 makes it a crime for any person knowingly and willfully to make to any Depmlment or agency of the United States any false, fictitious or ~audulent
statements or re resentations as to an matter within its 'urisdiction...
*U.S. GPO: 1992-7744117/67022
ACKNOWLEDGEMENT
STATE OF COLORADO )
COUNTY OF DENVER )
On the ~k'day of September, 2001, personally appeared before me Terry W. Donze who being by me
duly sworn did say that is authorized to execute this assignment on his own behalf.
Witness my hand and official seal.
~2~.~. · .'...'..o..0Z,~,
'N'~tary Public
~ '¢:" x.x, Ol/~'? ".? ~. Address: 1801 Broadway, Suite 800
~ ,,: : ~ Denver, CO 80202
,.. ~~oLo~Do
COUNTY OF DENVER )
On the i 2'~day of September, 2001, personally appeared before me Robert P. Jornayvaz III
who being by me duly sworn did say that he is the Attorney-in-Fact for Intrepid Oil & Gas, LLC, and is
authorized to execute this assignment.
Witness my hand and official seal.
My Commission Expires: (qt
Not~'r~ Public
Address: 1801 Broadway, Suite 800
Denver, CO 80202