HomeMy WebLinkAbout878420 DEPARTMENT OF ~ ~OR FORM APPROVED
:' '" ' B~A~'O~:~ ~G~ME~ OMB NO. 1004-0034
Expires: December 31, 2001
ASSIGNMENT QE:~g~O~RDiT!I~LE INTEREST IN A
L~SE FOR OIL AND,~G~N~z~R ~E~H~'RMAL
' I ~ .......... tr ....... ~ ..................... ~t-- 15 3 26 7
'~ Eff~five Dam
PAGE~3 Mine~ ~Ng Act of 1~0 (30 U.s.C] lSl ,, ~.) (~ve~ Da~)
- Act for A~uk~ ~ of 1~7 (30 U.S.C. 351-359) June 1, 2001
. ~o~e~ S~ A~ of 1970' (30 ~.S.C. 1~121~5)
~pa~ent of ~e ~mfior Appropdafiom A~, F~ Y~ 1981 (42 U.S.C. 6508) New Serial No.
Typ~ or print'plainly In ink and si~n in ink.
PA~T A: ASSIGNMENT
L ~i~, Herbaly'E~l'oraticn LLC (50g)' Beartoo~ Oil 5 Gas Company (50~)
S~t 2412 N. b~ .Creek Ct. P.O. Box 2564'
Ci~, Sme.'~ C~, Littleton, Colorado 80120 Billings,. Montana
*~ more ~ one ~sign~, ch~k here ~"~d hst ~e ~me(s) ~d address(es) of ~ adffifio~ assign~s on ~e revere of ~is fora or on a
. ~p~ate amch~ sh~t of pa~r.
~s r~ord fi~e ~si~ment is for: (~eck one) :~ Off and Gas ~se,. or ~ G~e~ ~e
hterest conveyS: (Check one oP both, e~ appropdate) ~ R~ord Title, ~ ~e~ng Royal~, payment out of pr~uc~on or o~er s~il~
~mresm or payment.
2. ~ ~si~ent mnveys ~e fo~ow~. ~
~d ~sc~pfion . Percent of hmr~t Percent of
A~ho~ s~ce 9n myer, if n~. Do not submt d~umen~ or a~mmenm other ~n ~' Convey~ Re~ ~e~d~g RoyM~
': R~ ' ~ly
or
a '. .b c d ~ f
To~sMp 25 North, Rm~ge 114 '~est;
Section 24: Lots ~:12, W/2 100~ 100~ -0- -0- '-0-
Section 25: Lots 1-12,
Section 36: Lot 1
1,622.19 acres
Lincoln Count, Wyoming
FOR BLM USE ONLY--DO NOT WRITE BELOW TH[S LINE
U~D STA~ OF ~CA
~ ~ent N approved ~iely for a~ni~tlve p~s, App~ov~ d~ not w~r~t ~at ei~her p~ to
~ Assig~ent approv~ for a~ve deseH~ finds; ~ Assig~ent a~prov~ for a~ch~ lind
Assi~m~nt approv~ ~ff~ve ~ Assi~ent approv~ For I~d d~c~pfion in~ted on ~v~
' of ~is fora.
By __ ~:'J?'7~':]:~ . ::
:"".::~- .:. -.. . ...
Part A (Continued): ADDITIONAL SPACE for Names and addresses of additional a~signees in Item No. I, if needed, or for Land Description in Item No. 2, if
needed. '
8,19
PART B: CERTIFICATION AND REQUEST FOR APPROVAL
The Assignor cerlifics as owner .if aq interest in Ihe above deslgaated lease Ihat he/she hereby assigns Io Ibc above*assignee(s) thc rights Specified above.
2. Assignee certifies as follows: (a) Assignee is a citizen of the United Stales; an association 'of such citizens; a man icipality; or a corporation organized undfir the
laws of ire United Stales or of anySlateor territory thereof. For the assignment ofNPR-Aleaaes, assigneeis a citizen, nalional, or resident alien of the Uniteri
States or association of such cilizens, nationals, resident aliens or privale, public or municipal corporations, (b) Assignee is not considered a minor .ader
laws of the Stale in which the lands covered by this assignment are located; (c) Assignee's chargeable interesls, direct and indirect, i0 each public domain and
acquired lands separalely in Ire'same stale, do not exceed 246,080 acres in oil and gas leases (ofwhigh ap to 200,000 acres may be in oil and gas options), or
300,000 acres in leases in each l~asing Dislriet in'Alaska of which up to 200,000 acres may be in options, If this is an oi1 and gas lease issued in accordance
with the Mineral Leasing ,Act of 1920, or 51,200 acres in any one Slate if this is a geothermal lease; (d) All parties holding an inlerest in the assignment are
otherwise in compliance wilh the regulations (43 CFR Group 3100 or 3200) and Ire authorizing Acts; '(e) Assignee is in compliance wilh rei:lamatlou'
requi'rements for all Federal oil a'nd gas lease holdin'gs as required by sec. 17(g) of the Mineral Leasing Act; and (D Assignee i's nol in violation of see. 41 of Ire
Mineral Leasing Act.
3. Assignce's signalure to this assignment conslilules acceplance Of al! applicable terms, conditions, stipulations and restrictions pertaining to the leas'e des,zribed
herein.
For geolhermal assignments, an overriding royally may not be less than one-fmlrth (1/4) of one percenl of the value of outpul, nor stealer the a 5; percent of thc rate of
royalty due Io the Uniled Stales when this assigt~menl is added to all previously created overriding royallie$ (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 28t11 dayof December . ~9 2001 Executed this 28th December 2001
but effective October 31, 2001 day of , 19
Mame of Assignor as shown on current lease Herbaly Petroleum Corp. Herbaly Exploration LLC
(Signature) Vice Pres(55dent A.ig~ /lmnbe~
or . or ('g)
Attorney-in-fac[ Attorney-in-fact ':
(Signature) (Signature)
I515 Arapahoe S'c. #1350 Executed thiS'" dgy of ' ' ,200
(Aisignor's Address) ~e-..mS/~th ~fi~g~is Company
Denver, Colorado 80202
(Ci~) (s~t~) ~zio Code)~~ President
Public reporting burden for this form is estimated to average 30 minutes per response including the time for reviewing instructions, gathering and maintaining d}ua, and
Managem~'ntC°mpleting and(1004.0034~,reviewino 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
, Bureau Clearance Officer, (WO-630),/vlail Stop 401 LS, 1849 C Street, N.W., Washington D.C. 20240.
Title 18 U.S.C. Sec. 1001 makes it a crime for any person knowingly and willfully ~o make to any Department ~r'agency of the United States any false, fictitious or fraudulent
statements or representations as to any mat~er within its jurisdiction.
STATE OF COLORADO
CITY AND COUNTY OF DENVER
The foregoing instrument was ~cknowledged before me this 28th day of
December, 2001 by David L. Herbaly, Vice President of Herbaly Petroleum Corp., a
Colorado corporation.
~.,). ..Witness my hand and official seal.
. ;> ,~ ,D xx,~: ,"~ ~ota~ P~blic' '
-., 1515 Arapahoe Street, ~1350
;~ .., ~:' . ' Denver, Colorado 8'0202
My commission expires: 08/06/02
STATE OF COLORADO )
) SS.
CITY AND COUNTY OF DENVER )
The foregoing instrument was acknowledged before me this 28th day of
December, 2001 by David L. Herbaly, as Member of Herbaly Exploration LLC.
Witness my hand and official seal.
t>IJ BX> 1515 ~apahoe Street, h1350
.' .. Denver, ColoradoS0202
My commission expires: 08/06/02
STATE 0F MONTANA )
CO'UNTYOF :*/[a'c.~5 ~..~e___ )ss.
· )
The foregoing instrument was acknowledged before me this t/t/../,, day of
· ..-J~.,~,'a c ~_f ., 20. 0,Zby Donald K. Roberts, President of Beartooth Oil & Gas
Company, a Montana corporation.
Witness my hand and official seal.
· ~'.4~.'...,,'.
:.. Notary Public
% ~,? "~L . ,
'",;q:..M¢~6mmission expires: l/