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CERTIFIED
to be a true and comparative copy
Of the: official records on file
Form 1 -1156
Ninth Edition
(August 1961)
UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
OFFER TO LEASE AND LEASE FOR OIL AND GAS
(Sec. 17 Noncompetitive Public Domain Lease)
The undersigned hereby offers to lease all or any of the lands described in item 2 that are available for lease, pursuant and subject to
the terms and provisions of the act of February 25, 1920 (41 Stat. 437, 30 U. S. C. sec. 181), as amended, hereinafter referred to as the
act, and to all reasonable regulations of the Secretary of the Interior now or hereafter in force, when not inconsistent with any express
and specific provisions herein, which are made a part hereof.
P W In on ,ro•..fie
I Mr.
Mrs.
1. Miss
L
2. Land requested: State
3. Land included in lease: State
RECEIVED 9/28/2011 at 3:44 PM
RECEIVING 961194
BOOK: 773 PAGE: 473
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
(Offeror does not fill in this block)
Effective date of lease
Mrs. Ruth R. Ellbogen
(First Name. Middle 1'nitial. Last Name)
P; 0. Box 1581
(Number and Street)
Casper, _.Wyoming 82602
City and State)
Parcel #671
County
Wyoming County
August 1, 1964
Lincoln
B y
J
Total Area 2361.39
4. Amount remitted: Filing fee $10, Rental -Total
5. Undersigned certifies as follows:
(a) Offeror is a citizen of the United States. Native born Naturalized Corporation or other legal
entity (specify what kind):
(6) Offeror's interests, direct and indirect, do not exceed 200,000 acres in oil and gas options or 246,080 chargeable acres in
options, offers to lease and leases in the same State, or 300,000 chargeable acres in leases, offers to lease and options in each leas-
ing district in Alaska. (c) Offeror accepts as a part of this lease, to the extent applicable, the stipulations provided for in 43
CFR 191.6. (d) Offeror is 21 years of age or over (or if a corporation or other legal entity, is duly qualified as shown by state-
ments made or referred to herein). (e) Offeror has described all surveyed lands by legal subdivisions, all lands covered by pro-
tracted surveys by appropriate subdivisions thereof, or all unsurveyed lands not covered by protracted surveys by metes
and bounds, and further states that there are no settlers on unsurveyed lands described herein.
6. Offeror is is not the sole party in interest in this offer and lease, if issued. (If not the sole party in interest, statements
should be filed as prescribed in Item 6 of the Special Instructions.)
7. Offeror's signature to this offer shall also consti.ute offeror's signe.t;,ro to and acceptance of, this lease and any amendment thereto
that may cover any land described in this offer open to lease application at the time the offer was filed but omitted from this lease
for any reason, or signature to, or acceptance of, any separate lease for such land. The offeror further agrees that (a) this
offer cannot be withdrawn, either in whole or in part, unless the withdrawal is received by the land office before this lease, an amend-
ment to this lease, or a separate lease, whichever covers the land described in the withdrawal, has been signed in behalf of the
United States, and (b) this offer and lease shall apply only to lands not within a known geologic structure of a producing oil or gas
field.at the time the offer is filed.
8. If this lease form does not contain all of the terms and conditions of the lease form in effect at the date of filing, the offeror further
agrees to be bound by the terms and conditions contained in that form.
9. It is hereby certified that the statements made herein are complete and correct to the best of offeror's knowledge and belief and are
made in good faith.
Offeror duly executed this instrument this day of 19
(Lessee signature) (Lessee signature)
(Attorney-in -fact)
This lease for the lands described in item 3 above is hereby issued, subject to the provisions of the offer and on the reverse aide hereof.
THE UNITED STATES OF AMERICA
T.
David B. Morgan
(Signing o
Form approved.
Budget Bureau No. 42—R990.4.
Office W
Serial No 0310647
)1/
R. Meridian
Total Area
Acres
T. 21N R. 112W :6th p Meridian
Sec. 2: Lots 5, 6, 7, 8, S
Sec. 4: Lots 5, 6, 7, 8, S�N2 Sf
Sec. 6: Lots 8 14, 51 2'4, S4St4i
EWl SE
Sec. 8 N SE -,NE, t
T. 22 N., R 112 W., 6th4.M.
Sec. 34: SW S2
Acres Rental retained $1181.00
y- -17t
(Title) l (Deb
Chief, Mineral Leasing Sf+¢tion
THIS OFFER MAY BE REJECTED AND RETURNED TO THE OFFEROR AND WILL AFFORD THE OFFEROR NO PRIORITY
F IT IS NOT PROPERLY FILLED IN AND EXECUTED OR IF IT IS NOT ACCOMPANIED BY THE REQUIRED DOCUMENTS
BUREAU OF LA MANAOEMEII(1t PAYMENTS. SEE ITEM 9 OF GENERAL INSTRUCTIONS
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.
Thle form may be reproduced provided that the copies are exact reproductions ea one sheet of both sides of this official form, in accordance with the previsions of r CFR