HomeMy WebLinkAbout894476i:orm :3000-3
(J~nuary 1996)
.... : ...... ' ' :UNITED STATES'
'DEPARTMENT OF THE ]~qTERIOR
ASSIGNMENT OF RECORD TITLE INTEREST IN A
LEASE FOR OIL AND GAS OR GEOTHERMAL RESOURCES
Mineral Lea. sing 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 Appropriadoms Act, Fiscal Ye. at 1981 (42 U.S.C. 6508)
Type or print plainly In Ink and sign In Ink.
PART A: ASSIGNMENT
FORM APPROVED
OMB NO. 1004-0034
Expires: September 30. 1998
Lca~ Serial No.
WYW-155830
Lca~ Effective Dat¢
(Ann. iversaO~ Date)
June I , 2003
New Serizl No.
A_qignc¢' See Attached : ' -53~ p, p4OE 6 5 2
s~, · e :: .. ':~ ........ RECEIVED' ~ t~coLN ~OU~
&'IN00LN COUNTY OLE~
Ci~, S~, ~ C~e ~ ~ .... ·
~p~a~ a~ch~ ~eet of pa~r.
,~, ,,~,,,=~ JEANNE
~ r~ord dfle ~sig~¢n[ is for: (CMc~ one) ~ ou ~d O~ ~, or O O~om~ ~ j~7,,~F..4EF',ER. ,,¢,',?,.~:,-~..~ ,,,,,:, ¥.,~
~terest conveyS: (Check one or both, ~ appropdare) ~ R~ord Tide, ~ Ove~ng RoyM~, payment out of pr~ucdon or o~er
~res~ or paymenu
2. Th.is a.ssi~xment conveys the followin~ interest:
ORRI
Land De-scripfion Percent of Interest Percent of
Add, floreal space on reverse, if needed. Do not submit documen~ or agr~meau other tha~ Owned Conveyed Reudned ovemding Royalty
th3a form; such docum~nU or agreemems studl only be referenced herein, or SL, nil~r Interests
Reserved Pre vic~.ty
or conveyed
a b c d e f
Townsh±p 23 Northt Range 1'12 Wes'tt 6th P.M. 2.5% 2.5% -0-
o£ of
Sect±on 9: SE/4 8/8tbs 8/8th
Sect±on 10: SW/4, W/2SE/4
L±nco].n County', Wyom'incj
Conta±n±ng 400 acres more or ]_ess
FOR BLM USE ONLY--DO NOT WRITI BELOW THIS LINE
UN~I~D STATE~ O¢ ~IF-R]CA
Thi~ aaslgnment is approv.ed solely for administrative pLLrposes. Approval does not warrant that either patty to this assignment holds legal or .
equi~ble fide to th2s lease.
[] Assignment approved for above described lands;
Assignment approved effective
[] Assignment approved for an. ached land description
Assignmenf approved for la~d description inWcated on reverse
of this fortn.
: ,:,:,:,:,~,?:' ::
By .. :
, ( A ulhc~r~ :, r~ CiH~ rz, r~
Part A (Continued): ADDITIONAL SPACE for Names and addresses of additional assignees in llem No, I, if needed, or for Land Description in Item No. 2, if
needed,
See Attached "Exhibit A" ~ [3
PART B: CERTIFICATION AND REQUEST FOR APPROVAL
The Assignor certifies as owner :q' al Jnteresl in Ihe Jbove deslgnalcd lease thai he/she hereby lsstgns to the above assignee(s) Ibc rights specified ~hove.
A~,ignce ccrllfies ss rollo,~,s: (~) Assignee is a chizen of the Untrod States; an a~ociatlon of such clllzcns; i municip~llly; or ~ corpor~llo~ organized ~ndcr
I~'s o[ Ibc Untied 5~les or of ~ny SIdle or territory Ihcrco[. For ~hc ~ssignmcnl of NPR-A lc~ses, ~igncc Is ~ citizen, nJlionsl, or reside~l ~llc~ or Ibc UnHcd
SIxtes or ~ssoci~lion of su, ch cilizcns, n~lion~ls, .rcsldcnl ~Hens or priw~c, public or municipal cor~r~lions, (b) Assignee Is nol considered ~ ml~or ~dcr
laws of ~he S~e in which Ihe hods covered by IhJs ~sslsnmen~ ~re Ioc~led; (c) Assignee's ch~rge~ble Inleresls, dlrccl ~nd lndJrecl, In eich public domsi~ ~nd
~cquired bads s~p~r~lely in th~ same Sidle, do not exceed 246,080 seres in oil ~nd g~s leases (o(whiFh up Io 200,000 ~cres m~y be la oll ~nd g~s opHons), or
30n,000 seres in le~ses in each leasing Dislrlclln Al~s~ of which up1o200,000 ~cres m~y be'in npllon~, if this Is ~n oil ~nd 8~s le~se issued I~ ~ccotd~ncc
wi~h Ihe ~inc~l ~sing Acl o~ 1920, or ~1,200 ~crcs in soy one Slate if this is s geolherm~l le~se; (d) All p~rHes holding ~n in~eres~ in Ihe ~ssigomcal
o~he~g'~se in compllsncc wilh lhe regulsHons (a3 CFR Group 3100 or 3200) ~nd the sulhorizlng Acls; (el Assignee is In compliance with recbm~Ho~
requirements for ~11 Federal oil ~nd g~s le~c holdinss ~s required hy sec, 17(8) of Iht Mineral ~ssin~ Acl: lad (0 A.~slgnee Is nol In viol~llon of sec. 4
~lincr~l ~sing Ach
Assignee's sign~lure Io Ihls sssignmenl conslilules accel)lance of al! :~ppllc~ble terms, condhions, slipulallons and rcslriclions pcrlHnlng Io Ihe I~ase dc~rib~'J
herein.
For g¢olhcrmal assignments, an ovcrrldin8 royahy may nol bc les.~ Ihan one-fourth (I/a) of one pcrccnl o[ Ihe v31ue of ou~puh nor gre~er
roy~hy duc to Ibc UnHcd 51sle.~ when Ibis assignmcnl is ~ddcd Io all previously crc=~cd overriding royllllcs (,I] CFR 32a I ),
,'~ .'..~ ~'-'. , ~
[ cc~i~' ~al Ibc sralcmcn[~ made herein by mc arc l~c, complcle, and co.cci lo Iht ~sl o~ my knowledge one'lief and nrc mode in ~ faJ~,
Executed this 1_S_~ . day or O~-~h~_r' , ' ~ Executed this __ day of , 19
Name of As~signor a.~ shown on current lea,se Shawn P. Hannifin
P se ly~ or Print
Assig:nor .
or '
AUomey-in-fact
.¢~aturc)
P.O. Bo:< 8687
(Assignor's Address)
Denver/ Colorado 8020'1 -8687
(City) (State) (Zin Code)
As.slgne~
or
Attomcy-ln-fact
(Signa~Jre) .
(Signature)
Public reporting burden for thb form is est/mated to nvernge 30 minutes per response nc udin~; [he lime for rev ew ng Instructions, gnthedn~ nnd n',t, JnmJning dnt.'~, nnd
completing andmviewing tho Form. Direct commenU regarding the burden estimate or any other aspect of ~hts form to U,S. Deparunent of t]~ Interior, Bm'mu of
Nlanagcment. Bureau Clem'anco orficer {DW.I I0), Denver Federal Center. Building 40. P.O, Box 2.504'7, Denver, CO 80225.004? and the Office of Maoag~ment and
Budget Paperwork Reduction Project {1004-0034), Washington, D.C, 20S03,
Tith~ I ~ U,.S.C. Sec. IOOI make,~ il a crime for any person knowinBly and wilifully to make.!9 any Department or agency of the Untied Slates any false, riclidou.s or fr3udule~tt
,inlY. mcr, t, .... '-.°' ..... "represen, : '.' ", any mailer ~i,hin ils juri.';diclion. .
G54
INDIVIDUAL
)~~.<j ) ss
CiTY & COUNTY OF )
e~ undersigned, a Notary Public in and for said County and State on this /_'f//~ay, of
,2003, personally appeared Shawn P. Hannifin, to me known to be t'he identical
person (s) who executed the within and foregoing instrument and acknowledged to me that h.__~e executed the
same as his free and voluntary act and deed for the uses and purposed therein set forth.
Given under my hand and seal of office the day and year last above written.
My commission Expires:
Notary Public
Address: 73t:SP
G55
E'XHIBIT "A"
Attached to and made a part thereof that certain Assignment of Overriding
Royalty between Shawn P. Hamfifin as Assignor and the parties listed below as
Assignees as to the percentages shown.
Name and Address Percentage of ORRI AsSigned
Shawn P. Hannifin and
Frances A. Hannifin as
Joint Tenants with right
Of Survivorship
P.O. Box 8687
Denver, Colorado 80201-8687
16.6667%
Alan R. Hannifin - A single Man
P.O. Box 8687
Denver, Colorado 80201-8687
16.6666%
Fall River Resources, Inc.
P.O. Box 13456
Denver, Colorado 80201-3456
Maureen S. Schultz
934 South Filhnore Way
Denver, Colorado 80209
16.6667%
25.0000%
Edward N. Agurkis, Jr.
475 17th Street, Suite 600
Denver, Colorado 80202
25.0000%