HomeMy WebLinkAbout953279-Form 30G0
(February 2002)
A_
z„Q ASSIGNMENT OF RECORD TITLE INTEREST IN A
11.31 t SE FOR OIL AND GAS OR GEOTHERMAL RESOURCES
kI D Mineral Leasing Act of 1920 (30 U.S.C. 181 et seq.)
LIA Act for Acquired Lands of 1947 (30 U.S.C. 351 -359)
v,t fo (i 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)
PART A: ASSIGNMENT
1. Assignee* Pioneer Natural Resources, USA, Inc.
Street 1401 17 Street, Suite 1200
City, State, Zip Code Denver, CO 80202
*If more than one assignee, check ri:nd list the name(s) and address(es) of all additional assignees on page 2 of this form or on a separate attached
here aper.
13v
This record title assignment is for: (Check one)
Interest conveyed: (Check one or both, as appropriate) IX
2. This assignment conveys the following interest:
Land Description
Additional space on page 3, if needed. Do not submit documents or agreements other than
this form; such documents or agreements shall only be referenced herein.
MASS. ASSIGNMENT OF RECORD TITLE SEE EXHIBIT "A"
LINCOLN COUNTY, WYOMING
This assignment is approved solely for administrative pur
equitable title to this lease.
Assignment approved for above described lands;
Assignment approved effective
(Continued on page 2)
a
(Authorized Officer)
UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
Type or print plainly in ink and sign in ink.
X
APR 0 1 Ma
Oil and Gas Lease, or I I Geothermal Lease
Record Title,
(Title)
FORM APPROVED
OMB NO. 1004 -0034
Expires: October 31, 2004
Lease Serial No.
See Exh "A" attache(
Lease Effective Date
(Anniversary Date)
December 1, 2006
New Serial No.
Overriding Royalty, payment out of production or other
similar interests or payments
Percent of Interest
Owned
b
Conveyed
c
Retained
d
Reserved
e
Percent of
Overriding Royalty
or Similar Interests
Previously
reserved
or conveyed
f
RECEIVED 5/7/2010 at 11:30 AM
RECEIVING 953279
BOOK: 746 PAGE: 707
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
i
FOR BLM USE ONLY -DO NOT WRITE BELOW THIS LINE
UNITED STATES OF AMERICA
poses. Approval does not warrant that either party to this assignment holds legal or
Assignment approved for attached land description
Assignment approved for land description indicated on reverse
t'"' 9S "her
La a cs a 3L, •LxSN s$2iKw
(Date)
.•OG7o7
sheet of
16 2010
Part A (Continued):` T D t'IUNAL SPACE for Names and addresses of additionara trrees in Item No. 1, if needed, or for Land Description' nrivo. 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 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
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 compliance with reclamation requirements for all Federal oil and gas holdings
as required by sec. 17(g) of the Mineral Leasing Act; and (1) 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 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. „1o/e) Executed this /,v day of 4411142k/ Executed this day of iCht1�l�$
But effective on lease date (12/1/06 or 6/1/07)
Name of Assignor as shown on current lease
Avalanche Energy, Inc.
Larkspur
Assignor
or John S. yer, President -.cr: Title:
Attorney -in -fa Attorney -in -fact
(Signature) /�,..r (Signature)
2403 Tenderfoot Drive Betty Brownson
(Assignor's Address) Attorney -in -fact
CO 80118
(City)
(Continued on page 3)
(Please type or print) Pioneer Natural Resources, USA, Inc.
(State) (Zip Code)
O
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 (1004- 0034), Bureau Information Clearance Officer (WO -630), Mail Stop 401 LS, 1849 C Street, N.W., Washington, D:C 20240.
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
fraud t, `;,,t statements or representations as to any matter within its jurisdiction.
(Forin 3000 -3, page 2)
a)
a)
C
O
N. Q
U
C
Q
u
as
p 0
CD
N a)
W
c
E FO- Z c
O O N as
U O 0 a)
X
a) C
W n O
c
O
.E4 (9 J
a)
E cc
C 0)
(1)
Q
(1)
a3
U
C
0
a)
c
W
N
0
c
f0
To
Q
a)
a)
CC u)
a)
0
a)
C
N
a)
a)
a)
O
U
a)
0
0 0 0
O 6 &`7O9
O O O O
O 0 7010 MAR -1 AM 9: 00
RECEIVED
D0! -BI M
z CH`= Y� W'! {fY
O O O 7 i. 1 1f i
O 0 0
O O O
O O O
O 0
O O O
O O O
O O o
O
O
O
O
O
O
O
O
0
0
N
d
a)
N
co
0
NI r W
a)
N
C6 c c (i
t(> Z
N
Z
M M M
'c N O O O
U
a)0 fn(OU)
O O
O O
O O
O O
T T
O
O
N
a)
z
N
N
a]
6-
Z
U
O
Z
CV
Q Q Q W N
N N N N
c c C C C
O O O O .O.
U U U .PD C
AU
0
ACKNOWLEDGEMENT:
STATE OF Colorado
COUNTY OF Denver
for ASSIGNMENT OF RECORD TITLE INTEREST IN A
LEASE FOR OIL AND GAS OR GEOTHERMAL RESOURCES FOR
LEASE NO.'S WYW 173646, WYW 173645, AND WYW 173644
Betty Brownson personally appeared before me and acknowledged that she executed
the attached Assignment of Record Title interest in a Lease for Oil and Gas or Geothermal
Resources as the Attorney in fact by and for Pioneer Natural Resources USA, Inc., a Delaware
corporation, and signed on behalf of said corporation.
WITNESS my hand and official seal this 10_ day of
2 -13 -13
y ew ttttattp t
a
NOTA
o
id P tt I L i
STATE OF Colorado
COUNTY OF Denver
My Commission expires:
February
2010.
A116.1
Notary Public: Gari -Ann Waite
&71a
John S. Geyer has sworn to me S. day of Feruary that the
Avalanche Energy, foregoing 9 instrument is a
valid instrument acknowledged by Jo hn Geyer, Presiden
WITNESS my hand and official seal. My Commission expires: 2 -13 -13
`lo ostttto k Notary Public: /2A) f`�,>vv 14-7;.2.
NOTA R y x
rj 'tl�•, t18 L I
Y
.o° P
y49 tt