HomeMy WebLinkAbout887332Form 3000-3
(Jantutry 1999)
UNITED STATES
DEPARTMENT OF THE IIWFE~OR
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 o-f 1947 (30 U.S.C. 351-359)
Geothermal Sleam Act of 1970 (30 U.S.C. 1001-1025)
Depar~ent of the Interior Appropriafioas Act, Fiscal Year 1981 (42U S.C. 6508)
Type or print pi?inly In Ink and slain In Ink.
FORM APPROVED
OMB NO. 1004-0034
Expires: December 31, 2001
Lease Serial No~
WYW-155075
Lease Effective Date
(Anniversary Dale)
2/1/02
New Serial No.
~'C_
" PART A: ASSIGNMENT ~....FIVE'D
1. A~ign~* Baseline Mine~ls, Inc L/NCO!_t,I CO~!?,!7y OLERK
S~t ~645 Court Place, Suite~
*~ more ~ one ~ign~, ch~k here ~' ~d ~st
~pm~ a~ch~ sh~t of pa~r. BOOK '"~ ...... PR PAGE
~s r~ord rifle ~si~ent.is for: (C~& OhO ~ Off ~d G~ ~e, or ~ G~e~ ~e
~terest conveyS: (Che& one or both, e~ appropNatO ~ R~ord Tide, ~ ~e~ng Roy~, payment out of pr~ucfion or o~er s~
~resm or paymenB
2. ~ ~si~ent conveys ~e fo~owm~ ~mre~t:
Land Description Percent of Interest Percent of
Additional space on reverse, ff needed. Do not submit documents or agreements other than Owned Conveyed Retained Overriding Royalty
this form; such documents or agreements shall only be referenced herein, or Similar 'Interes~
', R~rved Previously
or conveyed
a b c d e f
Townsh±p 22 North, Range qq4 Nest_, 6th P.M. 100% q00% 0% 2.S00% 0%
Sect±on qB: E2
Lincoln County, Wyoming
320 acres more or less
FOR BLM USE ONLY--DO NOT WRITE BELOW THIS LINE
UNITED STATES OF AM'~CA
This assivnment 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
(Autho6zed OffiCer)
[] Assignment approved for attached land description
[] Assignment approved for land description indicated on reverse
of this form.
(Tide) (Date)
Pan A (Conthmcd): ADDITIONAL SPACE for Names and address? of additionaJ assignees in Item No. l, if needed, or for 'Land Description in l~em No_ 2, if
needed.
ACKNOWLEDGMENT
The foregoing instrument was
°f-~-~N~V , 2003, by Brenda
/
My Commission Expires: ~/~/~
422
acknowledged before me this ~ <~/ day
Rovney, President.
~ ~ Commission # 13.~041 r
zz ~ Notary. Public - California ~
PART B: CERTIFICATION AND REQUEST FOR APPROVAL
I. The Assignor cer~it'ies as owuer .,[- aa in~crest in Ihe above designamd Ic:~se ,hat he/she hereby assigns lo ~he above assignce(s)?he rights specified al~'~'.'~[ \'
· ~- ~,,~,g,,5~ ce.TC,,:s2~ tol~o..¥s: ~a),~ss,gue,~. isa ci,i~e, or he U,,i,ed Sa ~s' ~ a~oe. o,, o~.~ ~i,~ .... · .... ~ ...................
~aw50t lac UU leo Stales or of any Stale or lerr of- I ' ~ ' ' ' ' - · ' · 1'="'7' ~' ~ ~u~pu~,JUn o~gaal~
~c aired la ~ - . , . . . , o g , ' d~r c
~ ~,~a~a ut wu~cu up Io zvu,uuo acres may be .m opuons, ~[ this is an oll :nd gas lease issued ia acCOrdance,' "
wilh (he Mineral Leasing Act of 1920, or 51,200 acres in any one Slate if this is a geothermal lease; (d) All parlies holding an inleresl
oihe~ise i. compliance with Ihe regulalions (43 CFR Group 3100 or 3200) and the authorizing Aris; '(e) Assignee is in compli:nce wilh
requirements for all Federal oil and gas leas'c holdings as required by sec. 17(g) of Ibc bline~al ~asing Act; and (0 ~signee ~ not in
Mineral ~asing Act.
3. Assignee% signalure IO Ibis assignmenl conslilules acceplance of al~ applicable Icrms, condilions, siipulalions and fcstriclions perlaining lO the lease de~fibcd
herein.
For gcolhcfmal ~ssignmenls, an overridiug ro~ahy may nol be le~ Ihau one-fourth ([/4) of one percent of Ibc value of oulpul, nor Stealer than 50 ~rceal of ibc fate ol
royally due to Ihe Uniled Stales when Ihis assignmeut is added IO all previou$ly crealcd overriding royalties (43 CFR 324 l).
I certify, that the statements made herein by me are true, complete, and correct lo the best of my 'knowledge and belief and are made in good faith.
Executed this~r'"'~L'- day oC JANUARY 2003
Name of .,L.s-%mor as shown on current lease Carlyle, Inc ..
or ~renOa Rovney -_ ~resident
Artorney4n-fact
(Signature)
15111 N. Hayden Rd #160-517
(ASSignor's Address)
Scottsdale, Ag 85260
(City) (State) (Zio Code)
Executed this ~ day of ~003
Ass BASELI ERAL~/, INC.
or J~h ~. Thames -- President
Art o m~j<in - fa ctX--.,._.~
,./ (Sig~mm)
Publi? r52porting burden Jbr ~his form is es6nmted to average 30 minutes per response including tile time for reviewing instructioos, gatherthg and ,nain[aining data, and
completing aod reviewing tile Ibrlll. Direct comfllen[$ regarding tile burden esthnute or ally ocher aspect of [bis fornl 1o U.S. Department of the Interior, Bureau ol' Land
b,'laoagemen[ (1004.-0034), Et l'einl C]'earance Of J'~cer, (WO-630), lVlail ::;top 401 Lg, I}149 C ..qn-eel, N W., Washington D.C. 20240.
Title 18 U.S.C. Sec. 1001 makes it a crime for any person knowingly and willfully to make to any Department or agency o£the United States any false, fictitious or fraudulent
statements or representations as to any manet within its .jurisdiction. '