HomeMy WebLinkAbout894805Form 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. 10014025)
Department of the Interior Appropriations Act, Fiscal Year 1981 (42 U.S.C. 6508)
FORlvl APPROVED
OMB NO. 1004-0034
Expires: July 31, 1995
Lease Serial No
W-136568
Lease Effective Date
July !, 1995
Type or print plainly In Ink and sign In ink.
PART A: ASSIGNMENT
1. Assignee* Joseph W. Thames
Street 1645 CoortPlace, SuitC422 "('~K_._~.'3~.0 I'~x -~A(]E .~. ~.5
City, State, ZIP Code Denver, CO 80202
R~C£ WE0 ~"
*If more thai, ooe transferee, check here [ ] a.d list ,lie name(s) aad address(es) of all additional traosferees on the ~et~rG{~J4~s l~t1~{)l ~tse~ae'hed
sheet of paper.
This transfer is f°r: CCheckone) [X] Oil and Gas Lease, or []Geothern, alSa9 ~ 8 0 5 03 0~T 28 l~.jt 91 5'b
Interest Conveyed: (Check one or both, as appropriate) [ ] Record Title. [ X l Overriding Royalty, payment out ofproduction.~ ,-m.~,, t~~"'°~O[ [k] E' WA G ~4 ~. ~
similar interests or payments ~'~-.:';: ~' ~ ~ L,'¢'~ ~L'" - ~ ;,z~¥C'~P '~'~ a~. !,:~ ~¢~e<l .?
2. This assignment conveys the followin§ interest:
Land 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
form; such documents or agreements shall only be referenced herein. . Reserved Previously
reserved
or
conveyed
A b e d e f
Township 22 North, Range 11.5 West, 6'~ P.M. 5.0000% .2500% 4.7500% Of Record Of Record
Section 22:S2S2
Lincoln County, Wyoming
160 acres more or less
(ORR! Only)
FOIl BLM USE ONLY--DO NOT WRITE BELOW Tills LINE
THE UNITED STATES OF AMERICA
This assignment is approved solely for administrative purposes. Approval does not warrant that either party to this assignment holds legal or equitable title to this lease.
[ ] Assignmenl approved for above described lands; [ ] Assignment approved for attached land description
Assignment approved effective [ ] Assignment approved for land description indicated Oh reverse of this form
By
(Authorized Officer) (Title) (Date)
Part A (Continued): ADDITIONAL SPACE for Names and addresses of additional assignees in Item No. 1, if needed, or for Land Description in item No. 2 if needed
ACKNOWLEDGMENT
STATE OF COLORADO
COUNTY OF DENVER
The foregoing instrument was acknowledged before me tiffs 18th day of August 2003, by Van K. Bt~lexck.
/\
Notary Pu~olic'' - -
:.L.-) ,j (.,.,, ~
· : '.;'".' ..' r~'
PART B: CERTIFICATION AND REQUEST FOR APPROVAL . . , ¢,~.
I. The Assignor certifies as owner of an interest in the 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 orsucl, citizens; a municipality; or a corporation organized under the laws of the United States
' or of any State or territory thereof 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, pt b c 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 domain 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 A aska of which up to 200,000 acres may be in options, if this is an oil and gas
lease issued in accordance with the Mineral Leasing Act or 1920, or 51,200 ,acres in any one State if this is a geothermal lease; (d) All parties holding an interest in the assignment are
otherwise in compliance with the regulations (43 CFR Group 3100 or 3200) and t ~e 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 (f) Assignee is not in violation of sec. 41 of the Mineral Leasing Act.
3. Assignee's signature to this assignment constitutes acceptance orall applicable terms, conditions, stipulations and restrictions pertaining to the lease described herein.
For geothermal assignments, an ovemding 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).
certify, that the statements made herein by me are true, complete, and correct to the best ormy knowledge and belief and are made in good faith.
Executed this 180' day of ,August
Name of Assignor as shown on current lease//' Ya~'~. Bullock.,
Attorney-in-fact
(Signature)
4530 South Verbena Street, Unit 381
2003
Executed this
Assignee:
Assignee:
or
Attorney-in-fact
(Assignor's Address) Assignee:
Denver, CO 80237-2599 .... '" '
(City) (Stale) ' (Zip Code)
Attorney-in-fact
day of August/IA
(Signature)
2003
Public reporting burden for this form is estimated to average 30 minutes per response including the lime for reviewing instructions, gathering and maintaining data, and
completi ]g and rev ew ng 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 (WO-771), 1849 C Street, N.W., Washington, D.C. 20240, and the Office of Management and Budget, Paperwork Reduction Project {1004-0034),
Washington, D.C. 20503
Title 18 U.S.C. Sec. I001 makes it a crime for any person knowingly and ;viii fully 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.