HomeMy WebLinkAbout928596
ÓUUJ..79
Form 3000-3
(May 2006)
UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
ASSIGNMENT OF RECORD mLE INTEREST IN A
LEASE FOR OIL AND GAS OR GEOTHERMAL RESOURCES
FORM APPROVED
OMB NO. l004-1Jœ4
Expires: April 30, 2009
Lease S~ No. B
E>Oï/!ib-
Lease Effi:ctive Date
(Annivel53l}' Date)
Mineml Leasing Act of 1920 (30 U.S.C. 181 et seq.)
Act for Acquired Lands of 1947 (30U.S.C 351-359)
Geothennal Steam Act of 1970 (30 U.S.C. 1001 -1025)
Department of the Interior Appropriations Act, Fiscal Year 1981 (42 U.S.C. 6508)
New Serial No.
Type or print plainly in ink and sign in ink.
DJ\ \ R fNA \ .C.....{ 'f« \.I 9\' 1.- PART}~: ASSIGNMENT
1. Miignee° GEoRGI/)< .JIL-v 0Ait\ -,I ~\.I5-r~ . '
~~StaII:,ZiPCode 3';'1{ EÙto Sft\'.INbS RDkC' Is. Assigoo- G~OI'\GIk' ,)H-\...- DkiR
\...--AF^\I f\r-t, Ck c¡ '({tl-4
OIf moce Ihan me assignee, cl1eck: ~ aOO list the name(s) aOO addres( ell) of all 00dti0nal æsignees on p¥ 2 oftlœ funn oc on a se¡m¡œ attæhed
sheet of paper_
'fhio¡recool title œsignmatisfir. (01eckone) c:;;:.~
InIr.rest conveyed: (Check one or both. as appropriate) RecœI Title,
Geahem1aI Lease
~Royalty,¡øymentoutof¡rodu;:tionOCother~
2 This sgnmmt ameys the 1bIIowing inIaest
L
Land Description Percent of Interest Percent of
Additional space on page 2, if needed. Do not submit documents or agreements Owned CooveyOO Retained ~en;id~ Royalty
other than this fonn; such documents or agreements shall only be referenced herein, Similar nterests
Reiemd Previously
~ æsem.d
or conveyed
a b c d e f
1ó tDN '5Y\l P 2.& No K(l-t . ~ 1\ ~GE U3 wes\ .315% . 31.'iøj.
S'(CÍ\O\"¡ 5'- e-.!:):, S~
8 - EÆz..NW, N~,N-ise/S~$e
')- V'J·t W'>-'2--j E\NW ( N£5W
RECEIVED 4/20/2007 at 10:40 AM
RECEIVING # 928596
BOOK: 655 PAGE: 179
JEANNE WAGNER
INCOLN COUNTY CLERK, KEMMERER, WY
FOR BLM USE ONLY . DO NOT WRITE BELOW THIS UNE
UNITED STATES OF AMERICA
This assigDment is approved solely for admin.istrative purposes. Approval does not "amot that either party to this assigDment holds legal or equitable
title to this lease.
Assignment approved for above described lands; Assignment approved for atlached land description
Assignment approved effective
Assignment approved for land description indicated on reverse
ofthis Conn
By
Bureau orland Management (BLM)
(Continued on page 2)
(Title)
(Date)
Part A (Continued): ADDITIONAL SPACE for names and addresses of additional assignees in Item No.1, if needed, or tor LaM uescnptlon ID Hem 1''IU. J., 11 111;:1;:111;:11.
O~ZS596
0001QO
l -........
PART B - CERTIFICATION AND REQUEST FOR APPROVAL
I. The Assignor certifies as owner if an interest in the above designated lease that helshe 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 of such citizens; a municipality; or a corporation organized under the
laws of the United States or of any State or territory thereof. For the assignment ofNPR-A leases, assignee is a citizen, national, or resident alien of the 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 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 anyone 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
requirements for all Federal oil and gas lease holdings as required bysec. 17(g) of the Mineral Leasing Act; and (f) Assignee is not in violation of sec. 41 of the
Mineral Leasing Act.
3. Assignee's signature to this assignment constitutes acceptance of aU applicable terms, conditions, stipulations and restrictions pertaining to the lease described
herein.
For geothennal assignments, an overriding royalty may not be less than one-fourth (114) 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 made in good faith.
.
Executed this
r '1/ day of ~ 1'1'; r V
20 01
Executed this
r -¿, day of
~ fl\ \ V 20 01
shown on current lease
..J (t~t" l)k\ R
Assignor
or
Attorney-in-fact
Assignee
or
Attorney-in-fact
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(City)
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(Assignor's Address)
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(State)
(Signature)
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(Zip Code)
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SEE ATTACHED
NOTARY FORM
Title 18 U.S.C. Sec.lOOI 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
ftaudulent statements or representations as to any matter within its jurisdiction.
(Continued on page 3)
(Form 3000-3, page 2)
O~Z8596
0001.·81
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
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State of California
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Dat.., _ Nam. and TIll. 01 omc.r (e.g.. 'Jane Do., Notary P\Jblic'
personally appeared GeOrai~, JrJ I 'J) Ai t\...
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~ proved to me on the basis of satisfactory
evidence
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LIlA S. QUESADA
Commission # 1680127
Notary Public - California ~
Contra Costa County
My Comm. Expires Aug 6, 2010
to be the person~whose name~&a¡;e-
subscribed to the within instrument and
acknowledged to me that be1ØfteOh~ executed
the same in , hi~erlJ:'titfír aU).Q9.4zed
capacity(ies), and t'rrcr(' by hi~r
signature(s) on the instrument the person~ or
the entity upon behalf of which the perso~
acted, executed the instrument.
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OPTIONAL
Though the information below is not required by law. it may prove valuable to persons relying on the document and could prevent
fraudulent removal and reattachment of this form to another document.
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Description of Attached Document
T1tJe or Type 01 DOCU7"'~ f'~
Document Date: tj. /2. D 1-
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folD· ~-J-~Jor ~ .
Num~ber of pages:d'~ ~ ~. )
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Signer(s) Other Than Named Above:
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Capacity(ies) Claimed by Signer ,J
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Signer's Name: \::1-é'A-rg I Cv ( A-I '"
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o Individual
o Corporate Officer - Title(s):
o Partner -.., 0 Limited 0 General
o ey-in-Fact
Trustee
o Guardian or Conservator
o Other:
Signer Is Representing:.:]) -Á1íL ~ L ~ 'J~T
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Reord.r. Call1bl~Fre. 1-00<1-816'6827
C 1999 NellonaJ Notary Associallon . 9350 D. Solo Av... :,0. Box 2402 . Chellworth. CA 9 1313-2402 . www.nalionelnotary.org
Prod. No. 5901
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