HomeMy WebLinkAbout899344Form 3000-3
UNITED STATES
DEPARTMENT OF T, HE INTER]OR
BUREAU OF LAND MANAGEMENT
ASSIGNMENT OF RECORD TITLE INTEREST IN A
LEASE FOR OIL AND GAS OR GEOTHERMAL RESOURCES
Mineral Leasing Act of ]920 (30 U.$.C. lg] et seq.)
Act for Acquired Lands of 1947 (30 U.S.C 35]-359)
Geothe;mal $1cam Act of 1970 (30 U.$.C. 1001-J025)
Department of the Inlerior Appropr a runs Act. Fiscal Year 1981 (42 U.S.C. 6508)
FORM APPROVED
OMB NO. 1004-0034
Expires: October 31, 2004
Lease Serial No.
!,/-0247.93
Lease Effective Date
(Anniversa~, Date)
February 1,
1954
New Serial No.
Assignee, R i c h a r d
Type or print plainly in ink and sign i:nk. 5 ;~"J'~;:i?i'Ti~,,'
PART A: ASSIGNMENT ! !o r,,~,,.~ ~'" '- ~ ,~ ~
L, Peterson Trus~, dat&~d"-~-~19-9-O ....................................
Stree~ P.O. Box 8
City, Slate, ZIP Code D o u g 1 a s, WY 8 2 6 3 3
*lfmore than one assignee, check here [] mid list the name(s) and address(es) of all additional assignees on the ri:verse ofthis form or on ~
separate anacbed sheet of paper.
This record, tij~ as~sign.?ent is for: (Check one) ~ Oil and Gas Lease, or l-'] Geod',e;mnl Lease
lmeresl conveyed: (Check one or both. as alvl~ropriate) [] Record Title. [~ Overriding Royally; payment ou! of production or other sJmila~
Jnleresu or payments
2. This assignment conveys lhe following interest: __
Land Description Percent of Jnleresl Percent of
AddilJoml space on reverse, if needed. Do not submit documents or agreements other than Owned Conveyed Relained Overriding Royalty
this form; such documents or agreements shall only be referenced herein. ' Similar Fnteresls
Reserved P~viously
· C :) r~s~rved
a K, D~ conveyed
h e d e
.o) -
To. whship 26 Nort. h, Range 113 West, 6t~ P.M.
section' 14: SE¼NW¼, SW¼ 0.9375% 0.9375% 0%
Section 22: E½NE¼, SW¼NE¼, SE¼NW¼
Section 23: Lot's 1,2,3,4, .N½NW¼
555
Section 26: Lots 1,2,3,4 BOOF ..... ]~P-:~'.!D 489
Containing 598.70 acres more or less.
ITE BELOW IHIS LINE ~7:~r% ----~: ~ r~
UNITED STATES OF AMERICA ': (.:-t, "( ~
This assignm~nl is spprowed solely for administrative p.rposes. Approval does not Warranl lbal eilher party Io lhj~'~'Ji~nmei].l. 0
equitable lille to this lev~se.
. holdFl'egal or
[] Assignmenl approved for above described lands;
Assignment approved cffecliv/: "
..'.. ,. '"7. :
By_
(Au~ho~ Offic~
-s:-) %i'~ co
[] Assignment.approved for attached lan~ description
[] Assignmenl approved for land description indicated on reverse
......... -' of.this form.
~mc)
(Continued on rever~e)
Part A IContlnued): ADDITIONAL SPACE for Names and addresses of additional assignees ' in item No. 1, if needed, or for Land Description in ltem No. 2. if
needed
STATE' OF WYOMING )
) ss
COUNTY OF CONVERSE ) O~)3ff~4' --. '- 4 9 0
The foregoing instrument was acknowledged before me by Richard L. Peterson~
this 26th day of March, 2004.
witness my hand and official
IDIANA K. EMERY- NOTARY PUBLICI
County of ~ State of I
Converse ~ ,Wyom, lngI
My Commission Expires ,June 19, 2007.
seal.
Di~&'K. ~ery-'-N~tary ~Pub~.
PAI~'I' B - CEF;'I'IFICATiON AND i¢iSQUE3T FOR APPROVAL '
I. The Assignor cerlffies as owner if an interest in the above designated lease thai be/she hereby a~signs to the above assignee(s) the rights specified above.
2. Assignee certifies as follow~: (a) Assignee is a citizen of thc UnheJ St.~tes; an association of such citizens; a municipalily; or a corporation organized under Ibc
laws of the United Seines or of any State or ~errilory thereo£ For the assignment of NPR-A leases, assignee is a citizen, national, or resJden! alien of the Untie6
States or associalinn ofsnch citizens, na Jonals, residenl aliens or p~jvate, public or municipal corporations, (bi Assignee is not considered a minor under the
laws of the State in which the lands cove~ed by this assigmnenl are located: lc) Assignee's cbasgeab e interests, direct and indirect, in each public domain sod
acquired lands separately in the same Stale, do not e~ceed 246,080 acres in oil and gas leases (of which up to ~00.000 acres may be in oll and gms options), or
300.000 ac~es in leases Jn each leasing DJslricl 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 lhe Mineral Leasing Acl of 1920. or 51.200 acres in any one $1ale if this Js a geotherma lease; (d) A Il parlies holding an Jnlerest in the assignment are
otherwise in compliance whh the regulations (43 CFR Group 3 ! OO Or 3200) ~nd the authorizing Acts; (e) Assignee is in compllnnce whh reclamation
requhements for all Federal oil and gas lease holdings as required by sec. 17(g) of the Mineral Leasing Act; and (fi Assignee is not in violation of sec. 41 of the
lvtj, era Leasing Act.
3. Assignee's signature to this assignmeo,~t conslimles acceptance of all adp icab e Icrms cond/tiolis, slipulations and restrictions pertaining lo the lease described
herein.
For gend~ermal assignments an overriding myahy may nol be less thun one-fonrlh (1/4) t,f one percenl or th,: va ne of omput, nor greater than 50 perccnl of the rate of
royally due to the Unhed 8tares when this assignment is added to nil previousb, c,ealed overriding royalties (43 CFR 32.111). ·
] cerljfy that Ore statements made herein by mc are true. complete, and correct Io thc besl of my know]edge mad belief mad are made in good faith.
Execuledthis' 26th .. day of:March 1~04 Executedlhis 26th dayof March
~0~04
Name tffAssignor as shown on current lease Richard L. Peterson
~ O'le~e type o,' print)
or (Si~n~mc)
A llomey-in-fa~
(Sig,at~
P.O. Box 8
(Ass~gnoffs Addr~)
Douglas~ WY 82633
(Cie/) Isle) (Zip Code)
Richard L. Peterson Trust, Dated 10-25-1990
oX By: Richar~ig~t.~e~eterson, Trustee
Anorncy-in-fact
(Sign~ure)
Public reporting borden for this fom~ is estimalcd to a,'erage 30 miumes pe~ respon.~e including the time for rev,tv4ng instructions, galherin ~ and malnla n ~g data
completing and ~evlewing the fo~. Direc~ commems regarding lhe b wden es,ma~e o~ any other ~cl of Ihi~ form Io U S De a · '
Mana emenl {1~4 ~34 Bur~u lc r ' p nn,enl or,he Interior Bureau
'g - ), C aanceO~cer,(W~630),MailStop.101LS, ig49CSu~LN.~,W~lfi~o~D.C.~0~40 , , of Land
Title 18 U.S.C. Sec. 1001 makes it a crime for any j-~:rson knowingly and will£uliy to make ,o any Depanmem or agency of the United States an), false ficlitious or bandulcm
stalements or tel)~escntalions as Io any roamer wrU]J n ils jurisdiclion. ,
(Form 3000-3 (1/99) {page 2)