HomeMy WebLinkAbout961195Form 4 -1158
Ninth Edition
(August 1961)
Fa,
or nlninlr in ink
is ink.
1.,n..i ado,.
L
2. Land requested: State
Parcel No. 980
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.
I Mr.
Mrs M. E. Gellert
Miss
(First Name. Middle Initial, Last Name)
60 Broad Street
(Number and Street)
New York, New York 10004
(City and State)
3. Land included in lease: State Wyoming County Lincoln
1
County T.
Form approved.
Budget Bureau No. 42— R990.1.
Office Wyoming
Serial No. 0318355
R. Meridian
(Offeror does not fill in this block) Total Area 960 .00 Acres Rental retained 480 00
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):
(b) 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 constitute offeror's signature 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 filin th ff f th r
RECEIVED 9/28/2011 at 3:52 PM
RECEIVING 961195
BOOK: 773 PAGE: 475
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
Total Area Acres
T.22N R.112W 65th P Meridian
Sec. 11: S$
Sec. 14: All
g, e o eror ur e
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)
(Attorney -in -fact) BUR E^ U OF LA
This lease for the lands described in item 3 above is hereby issued, subject to the provisions of the offer and 00 the reverse side hereof.
THE -UN.TTED STATES OF AMERICA
By
(Lessee signature)
(Bignlag di5eer)
41'1 231965
(Date
Effective date of lease AUG 1- 19615. .ASS1S1ANLM9t1NAG1 R OLL GAS
(Title)
THIS OFFER MAY BE REJECTED AND RETURNED TO THE OFFEROR AND WILL AFFORD THE-OFFEROR NO PRIORITY
IF IT IS NOT PROPERLY FILLED IN AND EXECUTED OR IF IT IS NOT ACCOMPANIED BY THE REQUIRED DOCUMENTS
OR PAYMENTS. SEE ITEM 9 OF GENERAL INSTRUCTIONS
18 U. S. C. sec. 5001 makes it a crime for any person knowingly and willfully to make to any Department or agency of the United
Slates any false, fictitious or fraudulent statements or representations as to any matter within its jurisdiction.
'^hla corm may be reproduced provided that the copies are exact reproductlous on 050 sheet of both sides of this official form, in accordance with the provisions of 43 QFR 192.42 (a).
ORIGINA
000475
CEFITMECY
be a trl an corrOarative copy
of the official r %cords on file
A 2 9 011
MANAGE