HomeMy WebLinkAbout894477~0,~ ~ooo-~
(January 1996)
UNITED STATES
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 se-at.)
Act for Acquired 'Lands of 1947 (30 U.S.C. 351-359)
Geothermal Steam Act of 1970 (30 U.S.C. 1001-1025)
Deparmaent of the Interior Appropriatioaa Act, Fiscal Year 1981 (42 U..S.C. 6508)
Type or print plainly In 'Ink and sl~ln In Ink.
OMB NO. 1004-0034
Exp~r,e~.. ~ O.qeli~cmber. 30. 1998
Lease Effective Date
(Anniversary Date)
June l, 2003
New Serial No.
,._PART A: ASSIGNMENT
A_qignee* See Attached ~7, ~;:O:~ F~- ·
s~ .... ~ LINCOLN COUNTY CLERK
~Slgfl~S Off ~e reveme of ~s ~6~ or on a
~terest convcy~: (Chtck ont or both. ~ appropriate) ~ R~ord Tide, ~ Ovc~ng Roy~, paym~n~ out of pr~ucfion or oSer
~rcs~ or paym~n~
2. This assilynment conveys the followint[ interest: ORRI
Land Description Percent of Interest Percent of
Additional space on reverse, il' needed. Do not submit document~ or agreemeo~s other than Owned Conveyed Rcudncd Ovemding Royalty ·
this form; such documents or agreements ~aH only b~ felon:aced herein, or Similar Interests
Reserved Previously
or conveyed
a b c d e f
Township 23 Northt Range 112 Westt 6th P.M. 2.5% 2.5% -0-
of of
Section 10: NE/4, NE/4NW/4 8/Sths 8/Sths
L±ncoln County, Wyom±ng
Containing 200 acres more or less
.FOR BLM USE ONLY--DO NOT WRITE BELOW THIS LINE
UNITED STATES OP AJ~ER/CA
This assignment is approved solely for adminiqrative purposes. Approval does not warrant that either party to this assignment holds legal or
equitable tide to thN lea~e,
[] Assignment approved for above described lands;
Assignment approved effective
(Authorized Officer~
[] Assignment approved for attached land description
[] Assignrnen{ approved for land description indicated on reverse
of this form.
Pan A (Continued): ADDITIONAL SPACE for Names and addresses of additional a~signees in Item No. 1, if neeJed, or for Land Description in Item No. 2, if
needed.
See Attached "Exhibit A" 657
PART B: CERTIFICATION AND REQUEST FOR APPROVAL
The Assignor cerlifies as owner ~f ;It intcresl in Ihe above deslgnalcd lease thai he/she hereby assigns Io Iht above assignee(s) ~he r{ghts spec[tied above.
Assignee certifies as roltows: (ar Assignee is a citizen of Ihe Untied Stales; an a~soci.~lion of such cilizcns; 3 municip,~llly; or a corporation organized under
laws of Ihe Unhed SOles or of any Slal¢ or lerrilory Ihereo[. For ~hc assignmenl of NPR-A leases, a...s[gnce is a cilizen, national, or resident alieu of Ibc Uni~ed
StAles or Assucblion of such citizens, nationals, resldenl aliens or privase, public or municipal corporalions, (b) Assignee is ual considered a minor u~dcr
hws of the Sale in which iht lands covered by Ibis assignmenl ~re loc~ted: (c) Asslgnee's chargeable inleresls, dlrecl and indlrecl, in tach public domain and
acquired I~nds separalely in Ihe same Stale, do nol exceed 246,080 acres in oil and gas leases (o[ whkh up ~o 200,000 Acres may bt Ju oll and gas opfio.s), or
)0o,000 acres in leases in each leasing Dis~ricl In AlAska o1' which up So 200,000 aere~ r.:~y be'in npllons, if Ihls is ~. oH and gas lea~e lssued In ~ccotd,.ce
wilh Ibc Mineral Leasing Act of 1920, or $1,200 acres in any one $1ale if Ibis is I geolhermal leascl (dr All parlies holding 3, interesl in the Jssignmcnl arc
olherwise in compliance whh the reguhfions (43 CFR Group 3100 or 3200) and Ihe aulhorizlng Acls; (er Assignee is in com'pHance wilh reclamal}on
requi'rcmcnts tar all Federal oil and 8as lease holdings ss required by sec. 17(g) of lhe Mineral Leasing Acl; and (f) Assignee Is not ~n violation of sec. 4 I of the
Mineral L~:ss~ng Act.
AssJgnce's signnlure Io Ihis asslgnmenl conslilutes acceptance of al! applicable Icrms, coadillons, slipulallons and rcslrictions perlAIning to Ibc le~se dcscrlbcd
herein.
For geolh~rmal assignmenls, an overriding royally may ual be le~ than one-foa.h (I/4) of one percent of Ihe value o1' oalpul, nor grealer than 50 perc.enl of the rule al
royH~y due In lhe Unhed Slales when this asslgnmenl is Added Io all previously cre:~ted overriding royallies (.13 CFR 32a I).
I certify thai the stalements made herein by me are true, complcle, and correct Io the bes! of my knowl;dg'~ d~' belief and arc made in good faith.
Executed this 1 st da), of October , : 200_3 Executed t,'iis ~: day of , 19
, . Shawn
Name or A~ignor as Shown on current lease
As~gnor _ _ . (8~g
OF
~_ Box 8687
(Assignor's Address)
Denver, Colorado 80201-8687
Hannifin
(City) (Smt~) (Zir~ Code)
A.~slgnee
A.orney-ln-fact
(Signature)
(Signature)
Public repo~n.~ burden for this form is estimated to average 30 minutes per response ncluding he time for' reviewing instruct ons, gathering and maintaining dam. and
completing ancfrnviewing the form. Direct commenls regardin~ the burden estimate os' ~my other asvect of this form ~o U.S Deparunent of the ln~erior. Bureau of L.lnd
Management. Bureau Clear.ce Officer (DW-110). Denver Fecteral Center. Building ,10 P.O. Box '25047, Denver, CO 80225-0047 and lhe Office of Management nnd
Budget. PaFerwork Reduction Project (004-0034), Washington, D,C. 20503. .
"Title ,18 U.S.C. S~c~ 1001 ma'.kcs il a crime for any person knowingly and willfully ~o make Io any Depanmenl or agency of the United Slalcs any false, fictitious or f~udulc.t
S~a~cmcn~ or rcpr~ as Io any muller within its jurisdiction. ':':;',?':";':~'
658
INDIVIDUAL
'STATE OF ~~Z~'~.~---e~ )
SS
efireme th un erst n o ~//t~ ·
..Befpr2 , e d 'g ed, aN tary Public in and for said County and State on this /'7 day, of
~,z'~7~~ ,2003, personally appeared Shawn P. Hannifin, to me known to be the identical
person (s) who executed the within and foregoing instrument and acknowledged to me that h._~e executed the
same as hi_~s 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: '--~/'~//~ -~O
Notary Public
Ad ess:2 O
659
EXHIBIT "A"
Attached to and made a part thereof that certain Assignment of Overriding
Royalty between Shawn P. Hannifin 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 wit h right
Of Survivorship
P.O. Box 8687
Denver, Colorado 80201-8687
16.6667%
Alan R. Hmmifin - 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
16.6667%
Maureen S. Schultz
934 South Fillmore Way
Denver, Colorado 80209
25.0000%
Edward N. Agurkis, Jr.
475 17th Street, Suite 600
Denver, Colorado 80202
25.0000%