HomeMy WebLinkAbout953387Form 31Q6 -14
(September 1982)
1. Assignee's Name
UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
TRANSFER, ASSIGNMENT, OR SUB145AIW, 25 AV, a 30
OF OPERATING RIGHTS IN OIL AHD GAS LEASE
SEE ATTACHED EXHIBIT "A"
Address lincluae srp coael
SEE ATTACHED• EXHIBIT "A"
Limited in
9,440 feet
Section 6,
PART I
3. Specify interest or percent of operating rights being conveyed to assignee
Executed this J �4"4") I� day of c r�
ENERGETICS OPERATING COMPANY
BY:
sAssignor's Signature)
Jo eph C. Mencin, Agent and Attorney -in -Fact
As•ignment approved effective
MAY 01 1985
B)'
AY-467, Hanson Fed. 10 -5
Hanson Fed. 30 -5
FORM APPROVED 7
OMB NO. 1004 -0034
Expires: August 31, 19B
Lease Serial No.
W -72845
Le•se,effective date
October 1, 1981
The undersigned, as owner of 87.5 percent of operating rights in the above designated oil and gas lease, hereby transfers, assicn,
and /or subl to the assignee shown above, the operating rights in such lease as specified below•.
2. Describe the lands affected by this transfer, assignment, and /or sublease (43 CFR 3101.2 -3 or 3101.1 -4)
Township 26 North, Range 111 West, 6th P.M.
Section 5: S /2NW /4, Lot 4, SW /4
Containing 279.84 acres, more or less, Lincoln County, Wyoming.
depth from the surface of the earth down to the stratigraphic equivalent of
as encountered in the Hanson Federal 40 -6 Well, located in the SE /4SE /4 of
T26N- R111W, Lincoln County, Wyoming.
This assignment conveys the same interest to Rocky Mountain Oilfinders, Inc. and DPM, Inc.
as that certain assignment recorded in Book 213PR, Page 397 (No. 615152) in the records of
Lincoln County, Wyoming.
5.5% of 11.733333%
.19 but effective as of July 15, 1983.
Englewood, Colorado 80112
RECEIVED 5/12/2010 at 10:22 AM
RECEIVING 953387
BOOK: 747 PAGE: 36
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
(Authorised Officer)
M
11.733333%
75.766667%
.645333%
8.625000%
4. Specify interest or percent of operating rights being retained by assignor
5. Specify overriding royalty interest being reserved by assignor
6. Specify overriding royalty previously reserved or conveyed, if any
7. If any payments out of production have previously been created out of this interest, or if any such payments are being reserved under thit-
transfer, assignment, or sublease, attic}, statement giving full details as to amount, method of payment, and other perunent ter...s
provided under 43 CFR 3106.
It is •peed that the obligation to pay any overriding royalties or payments out of production of oil crested herein, which, when •dded t:
overriding royalties or payments out of production previously crested and to the royalty payable to the United States, aggregate in excess o:
17 1/2 percent, shall be suspended when the ge production of per well per day averaged oil the monthly basis is 15 barrels or less.
1 CERTIFY That the Statements made herein are true, complete, and correct to the best of my knowledge and belief and are made in good faith.
00u036
102 Inverness Terrace East
(Assignor's Address)
(City) (State)
U.S.C., person knowingly and willfully to make to any department.or agency of the nice:
Tine l U.S.C., Section 1001 makes it •crime for any p
States any false, fictitious. fraudulent audulent statements or representations as to any matter within its jurisdiction.
THE UNITED STATES OF AMERICA
ANDREW L. TARSHiS.
Chief, O Et
Gas Sedictn
(Title)
NGTE Tr, r r, ....•'r- i ^'e'= t}.:: copes are excrr r•prodornoes or one shrri of born sides of rhrs °fits e a w
SEP 1 1 198$
(Date)
to be
0
ERTIFIED
true and comparative copy
ne official records on file
2 201
NAGEMENT
Agape Energy, Inc..
102 Inverness Terrace East
Englewood, Colorado 80112
Jordan R. Smith
102 Inverness Terrace East
Englewood, Colorado 80112
Robert L. Mehl
102 Inverness Terrace East
Englewood, Colorado 80112
Rocky Mountain Oilfinders, Inc.
102 Inverness Terrace East
Englewood, Colorado 80112
DPM, Inc.
102 Inverness Terrace East
Englewood, Colorado 80112
EXHI &IT "A"
3.168000%
1.100000%
2.713333%
3.168000%
1.584000%
aril 25 MA J a s
Attached to and made a part of that certain-Ass gnment'b`ft
Operating Rights, dated c 4 19'a4 by and
between Energetics Operating Company, Assignor and
Agape Energy, Inc., Assignee.
Notwithstanding anything to the contrary, it is hereby stipulated that:
1) That certain overriding royalty interest assigned to Continental Energy
Development Corporation from Energetics Operating Company through Assign-
ment dated July 20; 1982 and Stipulation dated September 27, 1983, shall
be borne by the assignees herein in that proportion to which their assigned
working interest bears to 73.333333
2) The assignees listed herein shall bear no part of any pre- existing overriding
royalty interest of record to Eaglewood Finance Company.
CERTIFIED
b true and comparative copy
the official records on file
I /APR 2 20
n 03
ASSIGNEE'S APPLICATION FOR APPROVAL OF TRANSFER
OF OPERATING RIGHTS AND /OR OPERATING AGREEMENT (SUBLEAS$)
A. ASSIGNEE CERTIFIES THAT the assignee and all other parties in interest (as defined in 43 CEtiii 310O.ti45(bh j huci s-
signment are:
1. Citizens of the United States or qualified' alien stockholders irl'a domestic'eorporation; association .of 'the' United States.
or any State or Territory thereof;'or municipalities.
2. Of the age of majority in the;State Where the lonsis'to be naeignttd .are located.
3. In compliance, with the acreage•limitatibd net 'kWh in'43 Ftii' '31'01.1.5 acid 3101.2 -4.
B. ASSIGNEE AGREES That, upon approval of this „transfer of operating rights ;and /or operating, agreement „(subleasel be t: ^e
authorized officer of the Bureau of Lantf'M$nageineht, he'1vi11 be'bound`by the terms and conditions of the lease descr:be.:
herein as to the interests covered by this assignment,including,.,but not limited ro, the obligation to conduct all opera:;; -s
on the leasehold in accordance wl .th,tpe°terms, :and 'conditioRs ofrtte +lease.; trocondition all wells for proper abandor.
restore the leased lands upon completion of any drilling operations as prescribed inthe lease, and to furnish and "r a:r:
such bond as may be required by the lessor pursuant toi.theregulations (43 CFR.3104.2).
C. IT IS HEREBY CERTIFIED That the statements made herein are, true,.compiete, and correct to the best of undersigned's
knowledge and belief and are made rn'eood faith.
Executed this day of MAR 7 1985
AGAPE ENERGY, INC.
BY:
L, a
(Assignee's Signature)
Carl Rennert, President
ATTEST:
By:
1. USE OF FORM Use only for assignment of operating rights
(rncludrng uoreing mirrrsts) in oil and no 1 If transfer
of operating rights u' accompanied by an operating agreement,
single copy of such agreement must be submitted with the
•saignment. If more than one transfer of operating rights is
made out of lease. separate instrument of transfer is
required for each assignment. A separate instrument of assign-
ment shall be used for each less• out of which an assignment
is nude.
FILING AND NUMBER OF COPIES File three (3) completed
_.PART 11.
19
INSTRUCTIONS
NOTICE
The Paper cork Reduction Act of 1910 (44 U.S.C. 3501 et seq.) requires us to inform you that:
This information is being collected pursuant to the law (43 CFR 3 3(e)).
This information will be used to create record of lease assignment.
Response to this request is required to obtain a benefit
102 Inverness Terrace East
(Assignee's Addre•a)
Englewood, Colorado 80112
Title 1:. U.S•C... Section 1001. makes it crime for any person knowingly and wilfully to make to any department or agency of the United
States ail, false, fictitious, ortraudulent statements or representations as to any matter within it• jurisdiction.
The Privsey Act of 19'f4 and the regulation an 43 CFR 2.46(d)
provide that you be furnished the following information in
connection with information requued by this •saignmeot and
request for approvaL
AUTHORITY: 30 U.S.C. et. aeq.
PRINCIPAL PURPOSE The information is to be used to
process the assignment and request for approval.
ROUTINE USES:
(1) The adjudication of the assignee's rights to the land or
rte e'JKtt.
(2) Doc- -entation for public information in support of nota-
tions made on land status retorts for the management,
disposal. and use of public lands and resources.
Transfer to appropriate Federal agencies when concur-
rence is requited prior to granting right in public
lands or resources.
(4)(5) Information from the record and /or the record will be
transferred to appropriate Federal. State, local or
foreign agencies, when relevant to civil, criminal or
'regulatory investigations or prosecutions.
EFFECT OF NOT PROVIDING INFORMATION all the in-
formation is not provided, the assignment may be rejected.
(City) (State) (Zip Code)
and manually signed copies in the •ppropriate BLM office. A
125.00 nonrefundable filing (*emu,/ accompany this •ssignmer.
File assignment within ninety (90) days alt,. dote of fine:
execution.
3. EFFECTIVE DATE OF ASSIGNMENT The assignment, tI
approved. takes effect oo the first day of the month following
the date of filing of all required papers. If •n operator's bon
is required. it must be furnished prior to approval of the
assignment.
GPO 1311•aaa
O O38
CE 1d(F41-D
to be true and comparative copy
the official records on file
2 2010
MANAGEMENT
Executed this day of
JORDAN R. SMITH
PART 11
ASSIGNEE'S APPLICATION FOR APPROVAL OF TRANSFE.R_,,.
OF OPERATING RIGHTS ANDiOR OPERATING AGREEMENT,ISUBUEASI L
A. ASSIGNEE CERTIFIES THAT the assignee and all other parties in interest (as n_43 3 1;QQ.0 —S( b)) in this as-
signment are: a !,I'n 4 3 ;rl
1. Citizens of the United States or qualified alien stockholders in a domestic corporation; association of the United States.
of any State or Territory thereof; or municipalities.
2. Of the age of majority in the State where the lands to be assigned are located.
3. In compliance with the acreage limitation set forth in 43 CFR 3101.1 -5 and 3101.2 -4.
B. ASSIGNEE AGREES That, upon approval of this transfer of operating rights and /or operating agreement (sublease)
authorized officer of the Bureau of Land Management, he will be bound by the terms and conditions of the lease descr:`e.
herein as to the interests covered by this assignment, including, but not limited to, the obligation to conduct all opera:“..--.s
on the leasehold in accordance with the terms and conditions of the lease, to condition all wells for proper abandon.- e-:,::
restore the leased lands upon completion of any drilling operations as prescribed in the lease, and to furnish and a: n.
such bond as may be required by the lessor pursuant to the regulations (43 CFR 3104.2).
C. IT IS HEREBY CERTIFIED That `the Statements made herein are true, complete, and correct to the best of undersig ned's
knowledge and belief and are made in /good faith.
t8S 19
102 Inverness Terrace East
(Afaignee's Signature) (A•signee'• Address)
Title 18 U.S.C., Section 1001, makes it 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 tc any matter within its jurisdiction.
.1. USE OF FORM Use only for assignment of operating rights
(including u orking rnirrrsts) in oil and gas 1 If transfer
of operating rights is accompanied by an operating agreement,
a single copy of such agreement must be submitted with the
assignment. 1f more than one transfer of operating rights is
made out of a lease, separate Instrument of transfer is
required for each assignment. A separate instrument of assign-
ment shall be used for each levee out of which an assignment
is made.
Z. FILING AND NUMBER OF COPIES File three (3) completed
INSTRUCTIONS
NOTICE
Englewood, Colorado 80112
(City) (state)
The Privacy Act of I974 and the regulation in 43 CFR 2.48(d)
provide that you be furnished the following information in
connection with information required by this assignment and
request for approval
AUTHORITY: 30 U.S.C. et. seq.
PRINCIPAL PURPOSE The information is to be used to
process the assigruaent and request for approval.
ROUTINE USES:
(1) The adjudication of the •signee's rights to the land or
re•canea.
(2) Doc.- ,entation for public information in support of nota-
tions made on land status records for the management,
disposal, and use of public lands and resources.
(3) Transfer to appropriate Federal agencies when concur-
rence is required prior to granting right in public
lands or resources.
(4)(S) Information froth the record and /or the record will be
tr•nsferred to appropriate Federal, State, local or
foreign agencies, when relevant to civil, criminal or
regulatory investigations or prosecutions.
EFFECT OF NOT PROVIDING INFORMATION -If all the in-
form•tion is not provided, the assignment may be rejected.
'he Paperwork Reduction Act of 1980 (44 V.S.C. 3501 et seq.) requires us to inform you that:
Tis ir,fotr ration is being collected pursuant to the law (43 CFR 3106- 3(c)).
'his information will be used to create record of lease assignment
'e sponse to this request is required to obtain a benefiL
and manually signed copies in the appropriate ELM office.
S2.5.00nonrefundable filing fee mum accompany this assignment.
File assignment within ninety (90) days a(trr date of tins:
execution.
(zip Code)
3. EFFECTIVE DATE OF ASSIGNMENT The asaigtment. if
approved. takes effect on the first day of the month following
the date of filing of all required papers. If an operator's bond
is required, it roust be furnished prior to approval of the
assignment.
GPO ele•a44
039
CERTIFIED
a true and comparative copy
of the official records on file
2 201
ANAGEMEN1
A. ASSIGNEE CERTIFIES THAT the assignee and all other parties in interest (as defingd4l 1Q1).( C5(b)) in this as-
signment are:
1. Citizens of the United States or qualified alien stockholders in a domestic corporation; •association .'of the United States.
or any State or Territory thereof; or municipalities.
2. 'Of the age of majority in the State where the lands to be assigned are located.
3. In compliance with the acreage limitation set forth in 43 CFR 3101.1 -5 and 3101.2 -4.
B. ASSIGNEE AGREES That upon approval of this transfer of operating rights and /or operating agreement (sublease) by -e
authorized officer of the Bureau of Land Management, he will be bound by the terms and conditions of the lease desc ::be_'
herein as to the interests covered by this assignment, including, but not limited to, the obligation to conduct all opera:;c -s
on the leasehold in accordance with the terms and conditions of the lease, to condition all wells for proper abandon- ,e
restore the leased lands upon completion of any drilling operations as prescribed in the lease, and to furnish and r..a:r.:a:
such bond as may be required by the lessor pursuant to the regulations (43 CFR 3104.2).
C. IT Is HEREBY CERTIFIED That the statements made herein are true, complete, and correct to the best of undersigned's
knowledge and belief and are made in good faith.
Executed this
ROBERT1L. MEHL
ASSIGNEE'S APPLICATION FOR APPROVAL OF T ANS RER
OF OPERATING RIGHTS AND /OR OPERATING AGREEm ,T,(SUBL'E A;S:E)._:
day of
(2)
(3)
085
1. USE OF FORM Use only for assignment of operating rights
(rncludtng uorktng interests) in oil and gas 1 If transfer
of operating rights is •ecomp•nsed by an operating agreement,
single copy of such agreement must be submitted with the
assignment. If more than one transfer of operating rights is
made out of lease, separate instrument of transfer is
required for each assignment. A separate instrument of assign-
ment shall be used for each ley• out of which an aaugrunent
is made.
(Aisignee's Signature)
(Assignee's Addres•)
2. FILING AND NUMBER OF COPIES File three (3) completed
PART 11
19
INSTRUCTIONS
The Paperwork Reduction Act of 1980 (44 V.S.C. 3501 et seq.) requires us to inform you that:
This information is being collected pursuant to the law (43 CFR 3106 3(c)).
This information will be used to create record of lease assignment
Response to this request is required to obtain benefit
102 Inverness Terrace East
Englewood, Colorado 80112
(City) (State)
(Zip Code)
Title 18 U.S.C., Section 1001, makes it crime for any person knowingly and willfully to make to any department or agency of the Unnrd
States any false, fictitious, or fraudulent statements or representations as to any matter within its jurisdiction.
NOTICE
The Privacy Act of 1974 end the regulation in 43 CFR 2.48(d)
provide that you be furnished the following information in
connection with information required by this •••agmitnent and
request for approvaL
AUTHORITY: 30 U.S.C. et. net.
PRINCIPAL PURPOSE The information is to be used to
process the assignment and request for approval.
ROUTINE USES:
(1) The adjudication of the •ssignee's rights to the land or
resources.
Doc entation for public intonation in support of not..
tions made on land status records for the management,
disposal, and use of public .lands and resources.
Transfer to appropriate Federal agencies when concur-
rence is required prior to granting right in public
lands or resources.
(4)(5) Information from the record and /or the record will be
transferred to appropriate Federal, State, local or
foreign agencies, when relevant to civil, criminal or
regulatory investigations or prosecutions.
EFFECT OF NOT PROVIDING INFORMATION If ell the in-
formation is not provided, the •ssignment may be rejected.
and manually signed copies in the appropriate BLM office. A
325.00 nonrefundable filing fee must accompany this assignment.
File as sagnment within ninety (90) days after date of fine:
execution.
3. EFFECTIVE DATE OF ASSIGNMENT The •ast -went, if
approved, takes effect on the first day of the month following
the data of filing of all required papers. If an operator's bon_
is required, it must be furnished prior to •ppro•l of the
s s ignment.
GPO •36.14•
0 040
1
nd cornpa tive copy
records on file
2 2010
!7D 7C 0! O: 3i.t
A. ASSIGNEE CERTIFIES THAT the assignee and all other parties in interest (as defined in 43 CFR 3100.0 -5(b)) in this as-
signment are:
1. Citizens of the United States or qualified alien stbckholders in a domestic corporation;; .asiociatioir'tisf4e United States;
or any State or Territory thereof; or municipalities.
2. Of the age of majority in the State where the lands to be assigned are located.
3. In compliance with the acreage limitation set forth in 43 CFR 3101.1 -5 and 3101.2 -4.
B. ASSIGNEE AGREES That, upon approval of this transfer of operating rights and /or operating agreement (sublease) by the
authorized officer of the Bureau of Land Management, he will be bound by the terms and conditions of the lease described
herein'as to the interests covered by this assignment, including, but not limited to, the obligation to conduct all operations
on the leasehold in accordance with the terms and conditions of the lease, to condition all wells for proper abandonment,to
restore the leased lands upon completion of any drilling operations as prescribed in the lease, and to furnish and maintain
such bond as may be required by the lessor pursuant to the regulations (43 CFR 3104.2).
C. IT Is HEREBY CERTIFIED That the statements made herein are true, complete, and correct to the best of undersigned's
knowledge and belief and are made in good faith.
Executed this day of 19
ROCKY MOUNT OILP-IND RS I C.
BY: �i L" 102 Inverness Terrace East
(Assignee's Address)
L.
ATTEST:
BY:
Terry
'(Assignee's Signature)
Cl rk Kiser, 'dent
Ti ha
ASSIGNEE'S APPLICATION FOR APPROVAL OF T.`.RJgNSFER .i
OF OPERATING RIGHTS ANC /OR OPERATING AGREEMENT (SUBLEASE)
2
J. ge, 3ecretap
1. USE OF FORM Use only for assignment of operating rights
(including working interests) in oil and gas leases. If transfer
of operating rights is accompanied by an operating agreement,
a single copy of such agreement must be submitted with the
assignment. If more than one transfer of operating rights is
made out of a lease, a separate instrument of transfer is
required for each assignment. A separate instrument of assign-
ment shall be used for each lease out of which an assignment
is made.
2. FILING AND NUMBER OF COPIES File three (3) completed
PART 11
INSTRUCTIONS
NOTICE
The Paperwork Reduction Act of 1980 (44 U.S.C. 3501 et seq.) requires us to inform you that:
This information is being collected pursuant to the law (43 CFR .3106-3(c)).
This information will be used to create a record of lease assignment.
Response to this request is required to obtain a benefit.
Englewood, Colorado 80112
(City)
Title 18 U.S.C., Section 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, orfraudulent statements or representations as to any matter within its jurisdiction.
The Privacy Act of 1974 and the regulation in 43 CFR 2.48(d)
provide that you be furnished the following information in
connection with information required by this assignment and
request for approval.
AUTHORITY: 30 U.S.C. et. seq.
PRINCIPAL PURPOSE The information is to be used to
process the assignment and request for approval.
ROUTINE USES:
(1) The adjudication of the assignee's rights to the land or
resources.
(2) Documentation for public information in support of nota-
tions made on land status records for the management,
disposal, and use of public lands and resources.
Transfer to appropriate Federal agencies when concur-
rence is required prior to granting a right in public
lands or resources.
(4)(5) Information from the record and /or the record will be
transferred to appropriate Federal, State, local or
foreign agencies, when relevant to civil, criminal or
regulatory investigations or prosecutions.
EFFECT OF NOT PROVIDING INFORMATION If all the in-
formation is not provided, the assignment may be rejected.
and manually signed copies in the appropriate BLM office. A
525.00 nonrefundable filing tee must accompany this assignment.
File assignment within ninety (90) days a /ter date of final
execution.
3. EFFECTIVE DATE OF ASSIGNMENT The assignment, if
approved, takes effect on the first day of the month following
the date of filing of all required papers. If an operator's bond
is required, it roust be furnished prior to approval of the,
assignment.
(State) (Zip Code)
GPO 836.844
d 0:,041
ERTIFEED
to be true and comparative copy
the ofricia! records on file
ii
2010
AGEMENT
ASSIGNEE'S APPLICATION FOR APPROVAL OF .TRANSFER 111
OF OPERATING RIGHTS AND /OR OPERATING AGREEMENT SU$LEA'SE)
A. ASSIGNEE CERTIFIES THAT the assignee and all other parties in interest (as „defipg tn143 F R c 1(J0 0 -5(b)) in this as
signment are: vu 11, I
1. Citizens of the United States or qualified alien stockholders in a domestic corporation; associ'atlon. of the United States;
or any State or Territory thereof; or municipalities. ii'iU
2. Of the age of majority in the State where the lands to be assigned are located.
3. In compliance with the acreage limitation set forth in 43 CFR 3101.1 -5 and 3101.2 -4.
B. ASSIGNEE AGREES That, upon approval of this transfer of operating rights and /or operating agreement (sublease) by the
authorized officer of the Bureau of Land Management, he will be bound by the terms and conditions of the lease described
herein as to the interests covered by this assignment, including, but not limited to, the obligation to conduct all operations
on the leasehold in accordance with the terms and conditions of the lease, to condition all wells for proper abandonment,to
restore the leased lands upon completion of any drilling operations as prescribed in the lease, and to furnish and maintain
such bond as may be required by the lessor pursuant to the regulations (43 CFR 3104.2).
C. IT IS HEREBY CERTIFIED That the Statements made herein are true, complete, and correct to the best of undersigned's
knowledge and belief and are made in good faith.
Executed this day of i” 19
DPM, INC.
RY:
ATTEST:
BY:
(Assignee's Signet e)
Roy A. Webley, Vice President
J� n K. Reynolds,
Secretary
1. USE OF FORM Use only for assignment of operating rights
(including working interests) in oil and gas leases. If transfer
of operating rights is accompanied by an operating agreement,
a single copy of such agreement must be submitted with the
assignment. If more than one transfer of operating rights is
made out of a lease, a separate instrument of transfer is
required for each assignment. A separate instrument of assign-
ment shall be used for each lease out of which an assignment
is made.
FILING AND NUMBER OF COPIES File three (3) completed
PART 11
INSTRUCTIONS
NOTICE
102 Inverness Terrace East
Englewood, Colorado 80112
(City)
The Privacy Act of 1974 and the regulation in 43 CFR 2.48(d)
provide that you be furnished the following information in
connection with information required by this assignment and
request for approval.
AUTHORITY: 30 U.S.C. et. seq.
PRINCIPAL PURPOSE The information is to be used to
process the assignment and request for approval.
ROUTINE USES:
(1) The adjudication of the assignee's rights to the land or
resources.
(2) Documentation for public information in support of nota-
tions made on land status records for the management,
disposal, and use of public lands and resources.
(3) Transfer to appropriate Federal agencies when concur-
rence is required prior to granting a right in public
lands or resources.
(4)(5) Information from the record and /or the record will be
transferred to appropriate Federal, State, local or
foreign agencies, when relevant to civil, criminal or
regulatory investigations or prosecutions.
EFFECT OF NOT PROVIDING INFORMATION If all the in-
formation is not provided. the assignment may be rejected.
The Paperwork Reduction Act of 1980 (44 U.S.C. 3501 et seq.) requires us to inform you that:
This information is being collected pursuant to the law (43 CFR 3106- 3(c)).
This information will be used to create a record of lease, assignment.
Response to this request is required to obtain a benefit.
(Assignee's Address)
(State) (Zip Code)
Title 18 ti.S.C., Section 1001, makes it a crime for any person knowingly and willfully to make to any department or agency
States any false, fictitious, or fraudulent statements or representations as to any matter within its jurisdiction,
of the United
and manually signed copies in the appropriate BLM office. A
525.00 nonrefundable filing fee must accompany this assignment.
File assignment within ninety (90) days after date of final
execution.
3. EFFECTIVE DATE OF ASSIGNMENT The assignment, if
approved, takes effect on the first day of the month following
the date of filing of all required papers. If an operator's bond
is required, it must be furnished prior to approval of the,
assignment.
00:042
ElTI
to b r ue and comparative; copy
he official records on file
U OF LC D ►r: CANAGEMENT
apo 936.944