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Home My WebLink About958046Land Description Percent of Interest Percent of Overriding Royalty Similar Interests 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. Owned b Conveyed y c Retained d Reserved e Previously reserved or conveyed f 1 R I 13 V4 3 N` n -I I RR.I. .U.5O 61:R1 .12 to be of t! C s.r i €FIFO a tt;e and c,amparative offici. Ecords P- F, LAN. copy on ill?. 2011 t, NAGENIENT l� 1S'E 5 1 5vv VV RECEIVED 2/11 /2011 at 11:58 AM RECEIVING 958046 BOOK: 762 PAGE: 362 JEANNE WAGNER LINCOLN COUNTY CLERK, KEMMERER, WY FOR BLM USE ONLY DO NOT WRITE BELOW THIS LINE Form 3000 -3 (January 2010) UNTiTri.D ,S TATES DEPARTMENT OF THE INTERIOR BUREAU OF LAND MANAGEMENT ASSIGNMENT OF RECORD TITLE INTEREST IN A kE If FOR OIL AND GAS OR GEOTHERMAL RESOURCES Mineral Leasing Act of 1920 (30 U.S.C. 181 et seq.) Act for Acquired Lands of 1947 (30 U.S.0 351 359) Geothermal Steam Act of 1970 (30 U.S.C. 1001 -1025) artment of the Interior Appropriations Act, Fiscal Year 1981 (42 U.S.C. 6508) Dk I R. Ik V t t TR U `�T PART,A: ASSIGNMENT 1. Assignee* o i� C i pc _it liar I) 1 R TT'R L S rG Street Bog 6 356i 5 C tv t-(C pIZ i s.! C>r:% ROOD City, State, Zip Code /4\ iN e ,c L( *If more than one assignee, check here and list the name(s) and addresses) of all addtional assignees onpage 2 of this form or on a separate attached sheet of paper. This record title assignment is for (Check one) Interest conveyed: (Checkone or both, as appropriate) Record Title, 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. ri la. Assignor Oil and Gas Lease, or Geothermal Lease 6-� FORM APPROVED OMB NO. 1004 -0034 Expires: July 31, 2012 Lease Serial No. Lease Effective Date (Anniversary Date) New Serial No. p� 6 (--)41\ 0363 C;: (j 1 c i r`"\ 1 tom.. r i t. Overriding Royalty, payment out ofproduction or other similar interests or payments 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. El Assignment approved for above described lands; Assignment approved for attached land description Assignment approved effective L1 Assignment approved for land description indicated on reverse of this form (Title) (Date) Part A (Continued): ADDITIONAL SPACE i.,, names aria' addresses of additional assignees in Item No.1, if needed, or for Land Description in Item No. 2, if needed. 0 I'(\ 5 W. Jo1 Az, T S T IRO T 359c.) Ec' o 5 N' i 1.1 6 R t LL F. \relvt L\ PART B CERTIFICATION AND REQUEST FOR APPROVAL 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. 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 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. I 3. Assignee's signature to this assignment constitutes acceptance of all applicable terms, conditions, stipulations and restrictions pertaining to the lease desc4bgd 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 aif,Z, 0 royalty due to the United States when this assignment is added to all previously created overriding royalties (43 CFR 3241). 1 1 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. ;4: Executed this f day of J ac K1 0 20 1 Executed this (1 day of j r v U 20 i l 3 Name of Assign' s shown on current lease Assignor or Attorney-in-get ature gN 3 C9 s 'G -t (Si c S eR G I.) GS RR M) (Assignor's Address) .9 rk (City) (State) (Zip Code) 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. (Continued on page 3) (Please typ or print) J W4 Assignee r r: tore) or Attorney -i o -fact (Form 3000 -3, page 2) to be n in a and corp< rrtive copy of th a icial records on file (Signa BU U OF LAN /1ANAGEMENT (Signature) 000363 2911 3 a I run CALIFORNIA ALL PURPOSE ACKNOWLEDGMENT State of California li County of L.:Lr 1 AA O n il, it, a0 I Dal personally appeared before me, z z LIZA S. OUESADA Commission 1894953 z Notary Public California Contra Costa County My Comm. Expires Aug 6, 2014 Place Notary Seal Above r Capacity(ies) Claimed by Signer(s) Signer Is Representing: Signer's Name: Individual Corporate Officer —Title(s): Partner Limited' 0 General Attorney in Fact Trustee Guardian or Conservator Other: _C._:, 's' .L.C: .:_C:Li:...._. =e:: �YCdr y 2007 National Notary Association 9350 De Solo Ave., P.D. Box 2402 Cha tawortIti 7�l1 BUR yvt 11 l FP f i J I DA-t 2 Name') of Signer( Signature, L OPTIONAL U OF LAND Here Insert Name and Title of the O i ces WITNESS my and a o cial AGEMFIUT seal. Signer's Name: Individual ID Corporate Officer Title(s): Partner Limited General Attorney in Fact Trustee Guardian or Conservator Other: Signer Is Representing: who proved to me on the basis of satisfactory evidence to be the persont,whose name( isre subscribed to the within instrument and acknowled ed to me that sh My executed the same in his r/ her authorized capacity(i and that by h' er /t ,sir signatureKon the instrument the person*', or e entity upon behalf of which the person( 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. Signature o Notary Public 003 )364 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. Description of Attached Document Title or Type of Document: A," ctrtt1'61 f 41n tin 1- Document Date: Number of Pages: Signer(s) Other Than Named Above* BIG HHU NT OFSIGIVER Top of Thumb here r 11 3 t)� r t 3 f�i�� s Iig4 \MIl x` y Item x5907 Reorder:Call Toll -Free 1-8d0•876 •6827 J nr on file