Loading...
HomeMy WebLinkAbout894797Form 3000-3 (October 1992 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 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) FORM APPROVED OMB NO 1004-0034 Expires: July 31, 1995 Lease Serial No WYW- 155030 Lease Effective Date February 1, 2002 Type or print plainly In Ink and sign In ink. PART A: ASSIGNMENT Street 1645 Court Place, Suite 422 ...... ~- City, State, ZW Code Denver, CO 80202 LINCOLN COUNTY CLERK *If more than one transferee, check here I ] and lis~ the dame(s) and ~aa~ ~ d t al transferees on the reve ~r ~ s~t~amched sheet of paper. This tr~ser is for: (Check onO tX) Oil~dGasLe~e, or []Geothem;al~ease ,JEANNE Interest conveyed: (Check one or both, as appropriate) ['X] Record Title. [ ] Oveniding Royal~, payment ofit of production br other similar interests or paymants 2. This assignment conveys the following interest: ' ' l'~and Description Percent of Interest Percent of Overriding Royalty Additional space on reverse, if needed. Do not submit documents or agreements other than this owned Conveyed Retained Or Similar interests [orm; such documents or agreements shall only be referenced herein. Reserved Previously reserved or conveyed A b c d e f Township 22 N0rtlL Range 114 West, 6a' P.M. 100% 100% 3% 0% 0% Section 5: All Lincoln County, Wyoming 642.16 acres more or less FOR BLM USE ONLY--DO NOT WRYI~ B~}..~. THIS EINE; [ d'~.;": '~n;.t 2Ci 50t; ~;~ This assignment is approved solely for administrative pu,oses. Approval does not w~an, that el~~,s,~~ ~~ [~u,ttle title ,o ~is Ieee. [ ] Assignment approved for above described lands; , [ ] Assigame.~~,,~ Assignment approved effective [ ] Assignment approved for land description indicated on reverse of this form By (Authorized O~cer) (Title) (Date) Part A (Continued): ADDITIONAL SPACE for Names and addresses of additional assignees in Item No. I, if needed, or for Land Description in item No. 2 if needed ACIOIOWLEDGMENT The foregoing instrument was acknowledged before me this __ My Comntission ExPires: /~,I/~, ~q... ' PART B: CERTIFICATION AND REQUEST FOR APPROVAL 1. The Assignor certifies as owner of an interest in tire 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 of any State or territory thereo£ For the assignment of NPR-A leases, assignee is a citizen, national, or resident alien of the United States or associations 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 domaio and acquired lands separately in the same State, do not exceed 246,080 acres in oil and gas leases (of which up to 200,000 acres may be in oil and gas options), or 300,000 acres in leases in each leasing District in Alaska of ~vhich up to 200,000 acres may be in options, if tiris is an oil and gas lease issued in accordance with the Mineral Leasing Act of 19;20, or 51,200 ,acres in any one State if this is a geothermal lease; (d) All parties holding an interest in the assignment are o~he~,vise 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 (0 Assignee is not in violation of sec. 41 of the Mineral Leasing Act. 3. Assignee's signa0.tre 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). l certify, that the statements made herein by me are tree, complete, and correct to the best of my knowledge and belief and are made in good faith. Name of Assignor as shown on current lease RC Michael Co Inc. Or Robert C. Michael - President (Signature) Attorney-in-fact Executed th is Assignee: Assignee: or (Signature) PO Box I 18 (Assignor's Address) Santa Barbara, CA 93102-0118 (City) (State) (Zip Code) 2003 ~y of~ Attorney-in-fact Assignee: Attorney-in-fact Public reportiog burden for this form is estimated to average 30 minutes per response including the lime 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, (Alternate) Bureau Clearance Officer Cwo-771), 1849 C Street, N.W., Washington, D.C. 20240, and the Office of Management and Budget, Paperwork Reduction Project (1004-0034), Washiugtou, D.C. 20503 Title 18 USC Sec. I001 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.