HomeMy WebLinkAbout868489Form 3000-3a
(May 1987)
tk (31
00 0- 21
I. Transferee (Sublessee)--- Baseline Minerals, Inc.
Street
City, State
Zip Code
Additional Transferees
UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
TRANSFER OF OPERATING RIGHTS (SUBLEASE) 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) WYW-148117
Department of the Interior Appropriations Act, Fiscal Year 1981 (P.L. 96-514)
Type or print plainly in ink and sign in ink.
1645 Court Pl., Suite 422
Denver, Colorado
80202
This transfer is for: (Check one) XIXOiI and Gas Lease, or Li Ocothermal Lease
Interest conveyed: (Check one or both, as appropriate) LX Operating Rights (sublease) 0 Overriding Royalty, payment out of production or other
similar interests or payments
2. This transfer (sublease) conveys the following interest:
Land Description
Percent of Interest
Additional space on reverse, if needed. Do not submit documents other than this form; Owned Conveyed Retained
such documents should only be referenced herein.
a
T22N R115W Lincoln County, Wyoming
Sec. 17 E2SE;
20 S2NE; 452
21 All; BOOK. PR PAGE 4 I 7
22 N2, N2S2;
28 All;
29 All;
2,560 Total acres
By /SI Carmen 5„ loviA
(Authorized Officer)
PART A: TRANSFER
e68t,89
FOR BLM USE ONLY
b
1 00%
l
c
100%
e
elow
3,000'
LAND LAW EXAMNER
(Title)
d
100%
above
3,000'
RECE1
r:
FORM APPROVED
OMB NO. 1004-0034
Expires: August 31, 1989
Lease Serial No.
1ED.
Percent of
Overriding Royalty
or Similar Interests
Reserved Previously
reserved
or conveyed
e f
5 1/2
0.
THE UNITED STATES OF AMERICA
This Transfer is approved solely for administrative purposes. Approval does not warrant that either party to this transfer holds legal or equitable
title to this lease.
I 11
AUG 0 1
/Tra Approved Effective
SEP 08 2000
(Date)
Part A (Continued): ADDITIONAL SPACE for Land Description in Item No. 2, if needed.
STATE OF Utah
SS
COUNTY OF Salt Lake
My Commission Expires: 1/15/2002
Executed this ,!y day of _o
6975 Union. =P,ark Center, Suite 310
(Transferor's Address)
Midvale, Utah 84047
(City) (State)
Executed this day of
ACKNOWLEDGMENT
(Zip Code)
Transferor
Medallicri
or
Attorney -in -fact
Transferee
tary Public
kit 110
0 1
On this 20th day of June, 2000, personally appeared before me Jake Harouny, whtis'ts'identity is personally
known to me, and who by me duly sworn, did say that he is the President of Medallion Exploration, a Utah
Corporation and that said document was signed by him in behalf of said Corporation by Authority of its
Bylaws and acknowledged to me that said Corporation executed same.
N
t um,. tna“-c111. u, llle va ue of output, nor greater tnan )0 percent 01 the rate 01 royalty
due to the United States when this transfer 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 hest of my knowledge and belief and are made in good faith.
19 Attorney -in -fact
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 :1987 181 423/64101