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HomeMy WebLinkAbout894809Form 3000-3 UNITED STATES (October 1992). DEPARTMENT OF THE INTERIOR FORM APPROVED BUREAU OF LAND MANAGEMENT OMB NO. 1004-0034 Expires: July 31, 1995 ASSIGNMENT OF RECORD T'ITLE INTEREST IN A Lease Serial No LEASE FOR OIL AND GAS OR GEOTHERMAL RESOURCES WYW- 156584 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) Lease Effective Date Department of the Interior Appropriations Act, Fiscal Year 1981 (42 U.S.C. 6508) Type or print plainly In Ink and sign In ink. PART A: ASSIGNMENT 1. Assignee* Baseline Minerals, Inc .... ' Street 1645 Court Place, Suite 422 ' , l ) 0K[ ~ 0 ~:X PA~ J-- 7 3 City, State, ZIP Code Denver, CO 80202 · *If more than one transferee, check here [ ]and list the name(s)and address(es)of all additional transferees on the reveq~.e{~{~0 ~'~a ~f~'~p~rra~ [~a~ sheet of paper. This transfer is for: (Checkone) IX] OilandaasLease, or [laeothermalLease89 L[ 8 0 9 {}3 OCT 2~ ~iN 01 5[~ Interest conveyed: (Check one or both, as appropriate.) [ ] Record Title. [ X ] Overriding Royalty, payment out of production or oth~rE.- i~ a ~ ~',t ~'"' ~ a t ^ t", M .E: [3 simila~ interests or payments ?, ~ r~l'q t'. E. ¥¥~ [~l.~l~l E, ft 2. This assignment conveys the followin~ interest: i'.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 form; such documents or agreements shall only be referenced herein. Reserved Previously reserved or conveyed A b c d e f Township 24 North, Range 114 West 6~ P.M. 100% 0.50000% 100% Of record Of record Section 8: NE, SW (ORRI Section 17: N2, SW ONLY) Section 20: N2, SW, N2SE Lincoln County, Wyoming 1360.00 acres more or less I FOR BLM USE ONLY-DO NOT BrRITE BELOW THIS 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. [ ] Assignment approved for above described lands; [ ] Assignment approved for attached land description Assignment approved effective [ ] Assignment approved for land description indicated on reverse of this form By ~ .~ . (Authorized Officer) (Title) (Date) Part A'(Continued): ADDITIONAL SPACE fOr Names and addresses of additional assignees in Item No. l, if needed, or for Land Description in item No. 2 if needed OL J480D 74 ACKNOWLEDGMENT STATE OF COLORADO COUNTY OF DENVER The foregoing instrument was acknowledged before me this~'-~,.--/o' day of 2003 b Nixon R Lan ¢ ann er ' v -]~["' - , , Y · g ~ g of Conaor~uxplo~atiqr't,.ELC. Notary Public PART B: CERTIFICATION AND REQUEST FOR APPROVAL 1. 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 of such 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, 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 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 Alaska 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 of 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 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 ibc Mineral leasing Act: and (Fl Assignee is not in violation of sec. 41 of the Mineral Leasing Act 3. Assignee's signature to this assignment constitutes acceptance of all applicable terms, conditions, stipulations and res~-ictions 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 ). I 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. (Assignor's Address) Greenwood Village, CO 801 ! I (City) (State) (Zip Code) Executed this Assignee: Assignee: or Attorney-in-fact · Asslgoee: ~ Allorney-in-facl Public reporting burden for this form is estimated to average 30 minutes per response including thc 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 0NO-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. 1001 makes it a crime for any person knowingly and willfully to make to any Deparbnent or agency of the United States any false, fictitious or fraudulent statements or representations as to any matter within its jurisdiction.