HomeMy WebLinkAbout966591Form 3000 -3 UNITED STATES
(January 1996) DEPARTMENT OF THE INTERIOR
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.C. 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)
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FORM AP ROVED
OMB NO. 004 -0034
Expires: Septe ber 30, 1998
Lease Serial No.
WYW- 80894
Lease Effective D to
(Anniversary Date
7 -1 -2012
New Serial No.
Type or print plainly in ink and sign in ink.
PART A: ASSIGNMENT
1. Assignee* Crown Energy Partners, LLC
Street 304 Inverness Way South, Suite 125
Englewood, CO 80112 la. Assignor: Ann M. Trujillo
City, State, ZIP Code
a separate
or other
*If more than one assignee check here
and list the name(s) and address(es) of all additional assignees on the reverse of this form or oz
attached sheet of paper.
This record title assignment is for: (Check one) I X
Oil and Gas Lease, or I I Geothermal Lease
Interest conveyed: (Check one or both, as appropriate) I X
Record Title, 1
Overriding Royalty, payment out of production
similar interests or payments
2. This assignment conveys the following interest:
Land Description
Percent of Interest
Per
Overridi
or Sinul
ent of
g Royalty
Interests
Additional space on reverse, if needed. Do not submit documents or agreements other than
this form; such documents or agreements shall only be referenced herein.
A
Owned
b
Conveyed
c
Retained
d
Reserved
e
Previously
reserved
or conveyed
f
T. 26 N., R. 111 W., 6 P.M.
100%
100%
0%
None
None
SECTION 19: E '/2 E '/2
160.00 Acres. Lincoln County, WY
RECEIVED 9/4/2012 at 10:35 AM
RECEIVING 966591
BOOK: 793 PAGE: 180
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
FOR BLM USE ONLY DO NOT WRITE BELOW THIS LINE
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.
Assignment approved for above described lands;
Assignment approved effective
By
(Authorized Officer)
Assignment approved for attached land description
Assignment approved for land description indicated on reverse
of this form.
(Title) (Date)
Part A (continued): twin TIONAL SPACE for Names and addresses of assignees in Item No. 1, if needed, or for Land D in Item No. 2, if
needed.
STATE OF WYOMING
COUNTY OF LARAMIE
This instrument was acknowledged before me this 13th day of August 2012, by Ann M. Trujillo.
Witness my hand and official seal:
7 /1a4kj_
1.
PART B: CERTIFICATION AND REQUEST FOR APPROVAL
The Assignor certifies as owner of 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 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 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 all 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).
I 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.
Executed this 13 day of August 20 12 Executed this Q� /V° day of ,q ,20
Name of Assignor as shown on current lease Ann M. Trujillo
Please type or print
Assignor f(' j'j 7 d Assignee
SS
or or
Attorney —in -fact Attorney -in -fact
(Signature)
P. O. BOX 1252
(Assignor's Address)
Cheyenne, WY 82003 -1252
(City) (State) (Zip Code)
MARY E. SCHEEH
COUNTY OF
LARAMIE
MY MISSION
(Signature)
o1 1
Public reporting burden for this form is estimated to average 30 minutes per response including the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the
form. Direct comments regarding the burden estimate or any other aspect of this form to U.S. Department of the Interior, Bureau of Land Management, Bureau Clearance Officer (DW -110), Denver
Federal Center, Building 40, P.O. Box 25047, Denver, CO 80225 -0047 and the Office of Management and Budget, Paperwork Reduction Project (1004- 0034), Washington, D.C. 20503.
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.
*U.S. GPO: 1996- 774 004/41005