HomeMy WebLinkAbout950520Land Description
Percent of Interest
Percent of
Overridin Royalty
Similar I
Additional space on page 2, if needed. Do not submit documents or agreements
other than this form; such documents or agreements shall only be referenced herein.
a
Owned
b
Conveyed
Y
c
Retained
d
Reserved
e
Previously
reserved
or conveyed
f
T. 20 N., R. 119 W., 6th Prin Mer.
Lincoln County, Wyoming
Section 4: Lots 5, 6, 7, 8, S/2 containing
453.96 acres, more or less.
ECEIVED 11/13/2009 at 12:34 PM
RECEIVING 950520
BOOK: 735 PAGE: 688
JEANNE WAGNER
COLN COUNTY CLERK, KEMMERER, WY
5% of
100%
ORRI
5% OF
100% ORRI
None
N/A
N/A
FOR BLM USE ONLY DO NOT WRITE BELOW THIS LINE
Form 3000 3
(May 2006)
UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
ttO LEASE FOR OIL AND GAS OR GEOTHERMAL RESOURCES
LIN
RECE, Mineral Leasing Act of 1920 (30 U.S.C. 181 et seq.)
n014 ,Act for Acquired Lands of 1947 (30 U.S.0 351 359)
ieothermal Steam Act of 1970 (30 U.S.C. 1001 -1025)
Department of the Interior Appropriations Act, Fiscal Year 1981 (42 U.S.C. 6508)
2. This assignment conveys the following interest:
By
(Continued on page 2)
Bureau of Land Management (BLM)
Type or print plainly in ink and sign in ink.
1. Assignee* NANCY J. WALISZEK, TRUSTEE DATED MAY 4,1989
Street P 0 BOX 3056
City, State, Zip Code FULLERTON CA 92834
This record title assignment is for: (Check one) SI Oil and Gas Lease, or Geothermal Lease
or payments
Assignment approved for attached land description
000688
FORM APPROVED
OMB NO. 1004 -0034
Expires: April 30, 2009
Lease Serial No.
W 82380
Lease Effective Date
(Anniversary Date)
January 1, 1983
New Serial No.
NANCY J. WALISZEK, TRUSTEE OF THE WALISZEK
la Assignor FAMILY TRUST DATED SEPTEMBER 15,1986
*If more than one assignee, check here and list the name(s) and address(es) of all addtional assignees on page 2 of this form or on a separate attached
sheet of paper.
Interest conveyed: (Check one or both, as appropriate) Record Title, 0 Overriding Royalty, payment out of production or other similar interests
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 effective Assignment approved for land description indicated on reverse
of this form
(Title) (Date)
Part A (Continued): 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
2009 NOV -6 AM 9: 00 000: 689
RECEIVED
OOI -BLM
CHEYE ?fF WYOMING
1. The Assignor certifies as owner if 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) 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 of NPR -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 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
requirements for all Federal oil and gas lease 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.
3. 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, 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 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 th 2nd day of NOVEMBER 20 09 Executed this 2nd day of NOVEMBER 20 09
Name of Assignor as shown on current lease Nancy J. Waliszek, Trustee of The Waliszek Family Trust dated September 15, 1986
Assignor
or
Attorney -in -fact
(Signature)
PO BOX 3056
FULLERTON
(City)
(Continued on page 3)
(Assignor's Address)
CA 92834
(State) (Zip Code)
(Please 1 •e .rint)
Assignee
or
Attorney -in -fact
(S gn f re) r
(Signature)
Title 18 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.
(Form 3000 -3, page 2)
DESCRIPTION OF TH ATTACHED DOCUMENT
cm a. C guifi, r CAL
1 (Title or description of
attached do.
ent)
(TRY; r description of
Number of Pages Document
ched document continue
Date
1 t 1 0
(Additional information)
2008 Version CAPA v12.10.07 800 -873 -9865 www.NotaryClasses.com
State of California
CALIFORNIA ALL PURPOSE
CERTIFICATE OF ACKNOWLEDGMENT
2089 NOV -6 AM 9: 00
County of ORANGE
On 'inO 02 U9 before me, MA- TERESA M. CRESPIN, Notary Public
(Here insert name and title of the officer)
personally appeared NANIC`( 3 WA 1-- ISZEK M ESS f NGt
who proved to me on the basis of satisfactory evidence to be the persone) whose name jpza&e subscribed to
the within instrument and acknowledged to me that sh /t ey- executed the same in �e /their authorized
capacity(itas), and that by ie '.thoir signature.(s) on t instrument the person(, or the entity upon behalf of
which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph
is true and correct.
WITNESS my hand and official seal.
J
Signature of Notary Public
CAPACITY CLAIMED BY THE SIGNER
Individual (s)
Corporate Officer
(Title)
Partner(s)
Attorney -in -Fact
Trustee(s)
Other
(Notary Seal)
ADDITIONAL OPTIONAL INFORMATION
RECEIVED
Ca1-BLM
CHEYENNE WYOMING
MA TERESA M. CRESPIN
Commission 1861749
Notary Public California
Orange County
1 t Al! Comm. Exeres Sep 16.2014
INSTRUCTIONS FOR COMPLETING THIS FORM
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