HomeMy WebLinkAbout963061Latid Description P
Percent of Interest P
Percent of
Additional space on page 2, if needed. Do not submit documents or agreements O
Owned C
Conveyed R
Retained O
Reseiverl P
Previously
reserved
or conveyed
Township 26 North, .Range 113 West, Gth P.M., Wyoming S
See S
See o
of record
LI
Form 3000 -3
(May 2006)
By
1. Assignee*
Street
City, State, Zip Code
(Continued on page 2)
UNITED STATES
DEPARTMENT OF THE INTERIOR
0 BUREAU OF LAND MANAGEMENT
ASSIGNMENT OF RECORD TITLE INTEREST IN A
LEASE 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)
Department of the Interior Appropriations Act, Fiscal Year 1981 (42 U.S.C. 6508)
See Exhibit "A"
Type or print plainly in ink and sign in ink.
*If more than one assignee, check here and list the names) and address(es) of all addtional assignees on page 2 of this foam or on a separate attached
sheet ofpaper.
This record title assignment is for: (Check one) I Y I Oil and Gas Lease, or [1 Geothcimal Lease
Interest conveyed: (Check one or both, cis appropriate)
2. This assignment convey the following interest:
This assignment is approved solely for administrative purposes.
title to this lease.
Assignment approved for above described lands;
Bureau of Land Management (BLM)
Record Title, 1
Assignment approved effective
PART A: ASSIGNMENT
la. Assignor See Exhibit "A"
UNITED STATES OF AMERICA
Approval does not warrant that either party to this assignment holds legal or equitable
E i Assignment approved for attached and description
Assignment approved for land description indicated on reverse
of this form
to be r, ye and Corn _para[ivr copy(Title)
clrw ur lde
'i<3t 1 Or 1.ANll Ii/!NIlai °;1 -11 /1F IT
FORM APPROVED
OMB NO. 1004 -0034
Expires: April 30, 2009
Lease Serial No.
WYE- 07798B
Lease Effective Date
(Anniversary Date)
New Serial No.
Overriding Royalty, payment out of production or other similar interests
or payments
(Date)
Part A (Continued): ADDITIONAL SPACE for names and addresses of additional assignees in Item No.1, if needed, or for Land Description in Item No. 2, if needed.
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 ofNPR -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.
3. Assignee's signature to this assignment constitutes acceptance of ail applicable terms, conditions, stipulations and restrictions pertaining to the lease described
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 of
royalty due to the United States when this assignment is added to all previously created overriding royalties (43 CFR 3241).
1 certify that the statements made herein by me are true, complete, and correct to the best of my knowledge ijd belief and are made in good faith.
dI
Executed this J L day of 20 Executed this day of
Assignor
Salt Lake City
Name of Assignor as shown on
1257 Third Avenue
(Continued on page 3)
PART B CERTIFICATION AND REQUEST FOR APPROVAL
ent lease Kearns Tribune Corporation
1 s
(Srenaturel
JW Gallivan, President
(Assignor's Address)
UT 84103
(City) (State) (Zip Code)
Assignee
Title 18 U.S.C. Sec.1001. makes it a crime for any person knowingly and willfully to make t y Department or agency of the United States any false, fictitious, or
fraudulent statements or representations as to any matter within its jurisdiction. E TA, j fl
.1 i�tnlu copy
u o Iicia,,reco n file
7 I f
1 n*•'A'NE;Ir so r' as Hai Nk -s6 °1Y r`k'
00727
204_
.rS Oil
pine King Inc
C.mpany
f✓ LL.c%/
earns Campb 1 Inves ment
(Form 3000 -3, page 2)
Attached hereto and mad part of Assignment of Overriding Royalty Interest m a Lease for OR and Gas:
Name
Kearns Tribune Corporation
to:
Name
A King Inc.
Ivers Oil Company LLC
Kearns Campbell Investments
Dated October 31 2011
Ex:Fp:fur "A"
Address
1757 Third Avenue SLC UT g4103
111 E Linclon Road Ste 4 Spokane WA 9g208
217 Cedar Street #C86 Sandpoint .11)
Signed for Identification:
c“
to I ikte copy
o i kd veLo%L.ot)..4:rhIl
Percent
11.111111111
Percent
6.99999999993 (63%)
2.88888888886 (26%)
L22222222221 (11%)
u 4
STATE of Utah
ss
COUNTY of Salt Lake)
CHEy 0 ,I /Z
On the 31st day of October 2011 before me personally appeared JW Gallivan "Iff
who being by me duly sworn, did say that he is the President of Kearns Tribune
Corporation and that said instrument was signed in behalf of said Corporation, who duly
acknowledged to me that they executed the ame.
My Commission expires:
August 30 2015
NOTARY PUBLIC
Residing at Salt Lake County
00729