HomeMy WebLinkAbout877138 Form 3000-3
(January 1999) ~ ~"
-~' ~ i: ~:u,~:~,_ UNITED'STATES
· , > ,. ,4, . DEPARTMENT OF THE INTERIOR FORM APPROVED
' BUREAU OF LAND MA. NAGEMENT OMB NO.
Expires: December 31,20~
, . ASSIGNMENT OF RECORD TITLE INTEREST IN I :,
,~i .......... ~ ~:.r.-, ~ ~,, ~,' i,,,~"~ ~S~rial No.
[.,,.,,~,L,[,:ii:L~ ? ;"::"~"'" LEASE FOR OIL AND (IAS OR GEOTHERMAL RESOURCES
~ ,~ :,~,~ '
~ J .~-Mineral l.,~asing Act of 1920 O0 U]$.C. 181 ,t ~eq.) ~ · ': ' (~naiwrsary Date)
act for Acquired Lands of 194'/O0 U.S. ¢. ~:5'i-359).Janu. ary- 1
"u :r D~pa, tment o,'~°~ermal Stun. Act of m.70 00 U.S.¢. m0~-102~)
,me Interior Appropriations Act, Fiscal Year 1981~-'~q,2 ~;g) '
and n In Ink. ~ -,
PART A: ASSIGNMENT
dated September 1.5, 19(36 ........... : .... --~x,~,.,-;. ,~:CI:'t¥
cig,, Sine, zip Code PO BOX 3056 L. IN0 ~ ~' .... , :'
....... L..~ : Ot:flt ',
J ~a~additional assignees on ~ '~''' ......... ~,'/
~parate attached sh~t of paper, s s
This r~cord ftle assignment is for: (Check one) ~ Oil and Gas Lease, or [] Geothermal Lease 'J ~'~-~,t~/f",ff i.' I. ? ~'; ;.: ff ti.':."
Interest conveyed: (Check one or both, as appropriate) [] Record Title, ~ .Overriding Royalty, payment out of production or other similar
_ interests or paymenls
2. ~ as$ijnm~nt co~¥e)t~ the followinj interest:
Land D~cription
Pcr¢~al of IntereSt Perc~l of
Additional space on reverse, if n~led. Do not submit documents or agreements other i Owned Conveyed Overriding Royalty
this form; such documents or asx~ment$ shall only be referenced herein. Retained .
or Similar Interests
Reserved Previously
or conveyed
T. ~O N. ~ lt. 119 ld., 6t:h Pr±ri. l'ler. ,b c d ,
Lincoln County, Wyoming 5% of ~% of N~ne .
100%
Section #: Lots 5,6,7,8,S/2 containing ORRI ?,{ 'ii~)ii!i!!i:i .... ..., : :
4'5~.96 acres, more or less. .
, .. ,1 ~!,
FOR BLM USE ONLY--DO NOT WRITE BELOW THIS LINE
UNITED STATES OF AMERICA . .
This assignment is approved solely for administrative purposes. Approval does/tot warranl/hat either party to lhLs asslgmnent holds legal or
equitable title to this lease.
[] Assignment approved for above described /ands; [~J Assignment approved for attached land description
Assignment approved effectiv~
[] Assignmeqt approved tbr land description indicated on reverse
of this 'form.
By
(Authorized Officer)
(Title)
(Dale)
T~ PART C: GENERAL INSTRUCTioNS lear
1. A~,ignorlAsaignee(s) must complete Parts Al and A2 and Part B. All parties to 5. hr any paytnent out of preducfion or shnilar interests, arrangements or payments
assignment must sign ~ follows: The assignor(s) must manually sign 3 original have previously been created out of the interest being assigned, or if any such
copies and the assigneeO) must manually sign at least I of the 3 original copies, payments or inll:r~ts am reserved under this assignment, include a stalzmem givi~
File Ihree (3) completed copies of this form in the proper BLM office for each full d,ztaiLs as to amount, method of payment, .
assignment of record title. For a transfer of overriding roynlty inter, st, payment under 43 CFR 3106, 3135, or 3241. and °ther pertinent terms aslmavided
out ofplxxluctlon or other similar intemt or payment, file one (l) manually signed 6. The lease account must be in good standing before this assignment call be
copy of thi.* form. The required filing fee (nonrefundable) must accompany the proved aa provided under 43' CFR 3106 and 3241.
assignment. File assignment within ninety (90) days after dale of execution of
assignor. 7. Assignment, if approved, takes ehrect on the first day of the momh following the
2. Separat~ form must be used for each lease being affected by this assignmeni and date of filing in the proper BLM office. If a bond i~ necessary, it must be fur-
for each type of in~,rest conveyed, n/shed prior lo approval of tbe assignment.
8. Approval of assignment of record title ~ 100% of a portion ofth~ leased lands
3. in Item No. 2 of Part A, describe laads affected (See 43 CFR 3106, 3135, or creates separate lea~ ofthe retained and the assigocd portions, but does no~ change .
3241). For columns b, c, d, stat e, enter the interest expressed as a percentage the tenm and conditions of the leas~ anniversary dale for purposes of payment
of total interest in the lease; e.g., if assignor assigns one quarter of a 20 ~ in- of annual rental.
tetr. st, enter 205 in column b, $~ in column c, and 159[ in coinum d.
9. Ovcrridiog royalty, paymt;nt out ufproductiou or other singlar types of transfers
4. If a.~ignmenl ia Io more than one axsignce, enter each assigne~'s mune across must be film with Bi.M, but will be accepted for record l~rposes only No off~-
colunma d, e, and fnent to the respective inlere.st being conveyed. Also I/st names cial approval will be given. '
nnd ~ of any additioml assignee(s) on reverse of this form or On, separate
attached sheet of paler`
U.S. GPO IaGo - ~ ~ .......
I'APEII WORK R 151)U(;TI()N ACT STATEM EN'F
I. This hfformalion is bci.g collcclcd imrsua.t lu Hm law.
2. This infbrmation will I'm used Io crcale a.d mai.l:dn n recm'd oF oil a.d ROUTINE USES:
3. ResI o.~e Io Offs requesl is rcq.hcd I{~ .blat. bt'ocDl. (l) The adjudication of ~e a~signee's rights to the l~d or ~our~s.
BLM WlRlld like you 1o know lhaf ytm do not have h) resp,md ~() Ibis or any other (2) .l)~uamn~tlon for public infomfion ~ supper of n~dom m~ on
vaFederalid (}MBage"cYco. lroiSl"ms°tedm.nlmr. ~ 'twl aHo. colleclion t.llcss il dispkB,s a cmremly records for ~e management, (lls~ml. and u~ of public l~
NO'I'ICE (3) Transfer to appropriate Federal asencies when concu.ence is ~ui~ prior to
The Privacy Act of 1974 and the regulation in 43 CFR 2.48(d) provide that you ~ gmnling a right in public lands or
fu~ished the following infor, mtio. in conneclion with' information required by ~i~ (4)(5) Information from the r~ord and/or O~e ~cord will ~ t~n~fe~ to appropd-
oil and ga~/geothermal le~e record title mqsignme.t application, ale F~eral, S~te. I~ or fo~ign agencim, when mlev~t to civil, cd~ or
A~HO~TY: 30 U.S,C. 181 el se~; 30 U.S.C. !~I-1~5; 42 U.S.C. 6508 to~ investigations or pro~utions.
E[FECT OF NOT PROVinG ~FO~ATION--B ~1 ~u~
P~NUIPAL PURPOSE--The intbrma0un is to ~ used Io pr~e~s record title as- tlon ~ not pro*ideal, the ~lgment m~y not ~ ~ppm.~..~
~Jgnment~ for o~ and g~/geo~hermal re~ource~ lea~es. 43 CFR Group~ 31ffi ~nd
State of California 3 4 ]_
County of Orange
On 10/4/2001, before me, Maralyn D. Schmiedeke , Notary Public, personally
appeared Stan F. Waliszek (personally known to me), Jane M. Waliszek (personally
known to me), and Nancy J. Waliszek (proven to me on the basis of satisfactory
evidence) to be the persons whose names are subscribed to the within instrument
and acknowledged to me that they executed the Same in their authorized capacities
and that by their signatures on the instrument the persons executed the instrument.
my hand and officialAseal. ~
WITNESS
, ' Not
~' ., " '~ ~ PART B: CERTIFICATION ~'ND REQUEST FOR APPRO
I, 'the Assig. or ce~liflc'} ~s .Whet ,[ al i.lcresl in Ih'e above designated lease that he/she hereby assig.s Io Ihe above assignee(s) Ihe Hghls speclfied ~bove.
2. Assignee cetlifies as follows: (a) AsMgnee isa c[tlzen of the Un{ledgtates; an a~ociafion of such chizFns;a munlclpallty;ora eorporalio~ organ{zed~der
laws of the Uniled Stales or of any Slale or terr tory thereof, }:or ~he assignment of NPR-A leases, asslgnee {sa citizen, national, or resident ~llea of the
States or associaHon of such cillzeas, naHonals, residenl aliens or privale, public or mu~icipal corporations, (b) Assignee is ,el considered I minor ~=der
laws o[ lhe Stale }~ which the lands covered by [his ass}g, menta, te ]oealed; (e) Assignee's chargeable [nteresls, dlrec[ and Indlrecl, in e~eh public domM= lad
acquired lands separalqly }n the same Slale, do not exceed 246,080 acres ia oll and gas leases (of which up to 200,000 acres may be in oil a~d gsa opllou$),
300,000 acres in leases in each leasing Dislricl in Alaska of which up:to 200,000 acres may be l. oplions, if Ibis is an oil and gas lease }slued la aecordaace
wi~h Ibc Mineral Leasing Act o{ 1920, or 51,200 acres in any one Slate if Ihis iS z ge01het~al lease; (d) All parties holding an interesl in the asslgnmeal
olhe~ise in compllanee wilh lhe regnlalions (da CFR Group 3t00 or 3200) and the authorizing Ac~s; (e) Assignee is in compliance wilh
requlremenls for all Federal oil and gas lease holdin'gs as required by sec. 17(g) of the Mineral l~asing Ac{; and (q AsMgnee is not in vioial{on of see. 41 o{ the
Mineral [~asing Act. '
3. herein.Asslg"ee's Mgna~ure to lMs asslg,men[ co.stilutes acceplance 0[ al~ applicable lerms, condhions, stipulations sad restrictions pertaining to Ihe lease
F,bt geolherma ass ga. eats, a, overrld~ng royalty may not be less Ihan one-fourlh (1/~) of one percenl of the value of output, nor greater than 50 ~reent of Ihe rate
'royally due lo the United Slates when this assignment is added fo all p~eviously created overriding royah}es (43 CFR 3241).
I ce~ify that the slalements made herein by me are tree. complete, and co~ect to the ~sl of my knowledge and ~lief and are made in g~ faith.
Executed this ___ day or ~.o~e~ , ~ .~QDi_ Executed this _ day orOctober , D 2001
Name of Assigoor as shown o,, current lease J~~W~ZEK THE W/LISZEK F~'IILY :TRUST daged
~ruseee~. or
~reby joins &, consengs '~o ~his assig~m~ 5 ~ ~r rus~ee or
P 0 Box 3056, iullerton CA 9283t~3056 Nancy Ol Waiisz~k, Trustee
(c~,~) (s,ate) (zi. c~) ~d Subsequent Trustees
Public rClmHing hurtle, for Ibis titan is esl{mated lo aver. ge 30 mim~teq per respo.se inclmlh}g the &lne for revlewi,g },strltcliong. galhefhtg n,d maintaining dale. and
compleli,g a,d r:~vicwi,g [Jl9 [orm. lib'ecl comme,ls regardi ~g lhe hurde, eslimale m a,y o{hcr aspecl of this form Io U.S. l)eparmmul of lhe Inlerior. Bureau of l.nnd
Mam~gcmcul ( I[10,:1 003.D.B.a,.au Clearaoce Officer, (W() 63(1). Mail Slop 401 I.S, 1849 C S reel. N.W, W,.~hinglou. I).C. 2.)1
Title 18 U,S,C. Sec. I(~)l makes il a crime for a.y ~rmn k.owingly and willfiflly to make to any Department or agency of the United Slates any fal~, ficlitiom~ or fraudulent
~talements or representations as to any mat*er within its jurisdiction.