HomeMy WebLinkAbout894816Form 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- 156598
Lease Effective Date
Type or print plainly in Ink and sign In ink.
PART A: ASSIGNMENT
i. Assignee* Baseline Minerals, Inc.
Street 1645 Court Place. Suite422 ' AaE__. 1.8 7
City, State, ZIP Code Denver, CO 80202
*If more than one transferee, check here [ I and list the name(s) and address(es) of all additional transferees on the rever~e of thi~'~'[~ ~['~t~e'p~rate attacbed
sheetofpaper. LINC0LN GOU TY
Thi~ tr~sfer is fo~: (C~ck oneJ ~ ] Oil ~d G~ Le~e. or [ ] Geothe~al Le~e
Interest conveyed: (Checkone or both. asappropriateJ[]RecordTitle. [X]~d~5[lt~pa~entoutofproduction~1 2~ ~I 03
simil~ interests or payments
dEANNE WAGNER
2. This assignment conveys the following interest: ~, ~: ~'~ C ~ ~ [~
~.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 e d e f
Township 24 North, Range l 15 West 62 P.M. 100% 0.50000% 100% Of record Of record
Section 34: N2, SW, NESE, S2SE (ORRI
Section 35: S2NE, W2, SE ONLY)
Lincoln County, Wyoming
1160.00 acres more or less
FOR BLM USE ONLY--DO NOT ~ RITE 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.
[ ] Assignment approved for above described lands; [ ] Assignment approved for attached land description
Assignment approved effective [ ] Assignment approved for land description indicated pn reverse of this form
By
(Authorized Officer) (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
188
ACKNOWLEDGMENT
STATE OF COLORADO
COUNTY OF DENVER
The foregoing instrument was acknowledged before me this ay of
My Commission Expires:
CA ~ ,avt~'\ 2003, byNixon R. Lange, Manager of Condpr'E.~lorati0~, EL.C-.'
(), -/'--'- ' ,'
Notary Public
PART B: CERTIFICATION AND REQUEST FOR APPROVAL
I. lhe 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; oi 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;
(q) 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 the Mineral leasing Act: and (t') 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 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 or' 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 true, complete, and correct to the best of my knowledge and belief and are made in good faith.
Executed this ay of 2003 Executed this
Name of Assignor as shown on current lease ~_.,~tlor Explp~tion, LLC Assignee:
ign°r'' or
Atturney-in-fact ~ ~g/natu!e, -- -.Att°racy-in'fact
7720 East Belleview Avenue, Suite B-102
(Assignor's Address) . Assignee:
Greenwood Village, CO 80111
(City) (State) (Zip Code)
Attorney-in-fact
155~~ day of ~
~ral$'lnc. /J//]
(Signature)
2O03
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
completing and reviewing the form. Direct comments regarding the burden estimate or any other aspect of this furm to U .S. Department of the Interior, Bureau of Land Management,
(Alternate) Bureau Clearance Officer (W0-771), .1849 c Street, N.W., Washington, D.C. 20240, and the Office of Management and Budget, Paperwork Reduction Project (1O04.4)034),
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 Department or agency of the United States any false, fictitious or fraudulent statements
or representations as to any matter within its jurisdiction.