HomeMy WebLinkAbout900895Fonn
(February 2002)
UNITED STATES
D ~
EPARTMENT OF THE INTERIOR
BUILEAU' OF LAND MANAGEMENT
TRANSFER OF OPERATING RIGHTS (SUBLEASE) IN A
LEASE FOR OIL AND GAs OR GEOTHERMAL RESOURCES
Mineral Leasing A~t of 1920 (30 U.S.C. 181 et seq.)
Act for Acquired Lfinds of 1947 (30 US.C 351-359)
Geothermal Sleam P~ct of 1970 (30 U.S.C: 1001-1025)
Department of the Interior Apptopiiafions Act, Fiscal Year 1981 (42 U,S.C. 6508)
Type or print plainly in ink and sign in ink.
FORM APPROVED
OMB NO. 1004-0034
Expires: October 31, 2004
Lease Serial No.
W-59774
Transfcree(Sublcssecp Richard L. Peterson Trust, Datedi'j'0~i'~'5' ;~0~ili':. ~;::: ........ ,'~,, ""/]
City, SUre, ZIP Code DOuglas, Wyoming 82633-0008 ~"~,'";:'~',oVd % .,5~:::- ,~:. :.:-,,'ac, O ~
*If more Ih~ onc transferee, check here ~ ~d list O~c name(s) ~d ad.ess(es) of ~ addilional ~fcrccs on thc rove~ ofthis fo~ or on a
sep~ate atla~hcd shect of paper:
This ~ansfer is for: (Check one) ~ Oil ~d Gm ~a~, or ~ Geothermal Lc~c
Interest conveyed: (Check o~ or both, as appropriate) ~ O~mfing Ri~ (sublet) ~ ~eniding Roy~, paymcn{ out of production or other
simila' interests or paymen~
2. Th~ Ir~sfcr (snblc~e) convis &e following intcr~st:
L~d
Addition~ s~cc on ~cnc, if~c~ ~ m Percent of
this fo~; such d~cnts or a~cmcnts
C
This overriding royalt
following in Lincoln
T. 26 N., R. 111 W.,
Section 6: Lot 2, E½
Containing 119.89 acre~
Description Percent of Interest
not Submit documents or agreements other tlum Owned Conveyed Retained Ove~
5 shall only be referenced herein.
. Rcsew,
:y covers the
:ounty, Wyoming.
:W~ t.6666 1.6666 -0-
E ONLY - DO NOT WRITE BELOW THIS LINE
UNITED STATES OF AMERICA
'vcrrmmg Royalty
Similar I-nterests
Previously
reserved
o~ conveyed
f
This transfer is approved solely for administrative purposes. Approval does not warrant that tither party to this transfer holds legal or
equitable title to this lease.
[] Transfer approved effective
By__.
(Continued on re verse)
(Au/horized Office:)
(Tille)
Part A (Cantinued). ADDITIONPuL SPACE far Name~ and addresses of addltional transferees
STATE OF WYOMING )
) ss.
COUNTY 0¥ CONVERSE )
iai Item No 1. if.needed, m for Lmtd L~acr~ptian m lmm No. 2. if
¢¢3'
The foregoing instrument was acknowledged before me bY Richard L. Peterson,
this 5th day of July, 2004.
Witness my hand apd official seal.
I DIANA K"EMERY ' NOTARV PUBLICI~
County of ~.~2# 'State of
I Converse, ~ W~,oming/
My uonuffzsslon ~xpxres: ~June "t~), 2007
Diana K. Emery -- NotarycfPublic
PART B- CERTIFICATION AND REQUEST FOR APPROVAL
The transferor certifies as owner if aa iatetcat i:a thc shave designated leilse that he/she hereby I~ausfers la the above assignee(s) the rights specified above.
'l'rasmfeo~¢ certifies as follows: (a) Tram/farce is a citizen at-the Llait~d Slates; an associalinn of such citizens; a msmicipality;
laws of lite United States or of any Stale or te?ritory thereof. Fur th~' lrilusfe[ of NPR-A Icase~. Ira~tsfer~¢ is a citizen, aatinnal, or residual alien of the Uah~d
States or associations of such cinzeas, nationals, residual alicn.s or private, public or municipal corporalinns. (b) Transferee is ua[ considered a lltillO[ nuclei' the
laws of thc State ia which the lauds covered by ibis lraasfc[' axe located; (c) T~unsfcree'~ cha~gcable interests, dirccl and iadirecl, ia each public domain and
acquired lands s¢parai~ty in the same Slate, donut exceed 246,0110 acres ia oil and gas leases (er which up ta 200.000 acraa may be ia oil and gas optiams), ur
30O,O00 acres in leases ia ¢ach leasing Disiricl in Alaska of which up to 200,000 ac[ts may be ia upliaaa, if this is aa oil and gas lease issued ia accordance
with th~/vlhtensl L~a~iag Act of t920, ar 51,200 a~rcs in any one S~'~ if Ods ia a gcotherm~ lea.sc; (d) All piulies holding
otherwise in cotaptiance with the regulation, s (43 CFR Group 31 O0 or 3200) and il)c uuthot~zmg Acts; (c) Tr, msfcr~ is in complimtce with reclamation
requiremeuls far alt Federal oil and gas I~asc aaldia§s as rcquh'ed by sec. [7(g) of the Mia¢i'al Leasing Act; auld (f) Transferee is ant ia vialatioa of sec. 41 uf the
Micro-'al Leasing Act.
Transfercc's sigaattuc te ilds assignment co~t/tt'les acccpm, nc¢ of all applicatile t~m~s, caadilioru% stipulations ami restrictions pcrlaiaiag lo the lease described hcreitL
Appticabl~ terms auul conditions iachide, but a~c sol limited lo. an obhgatioa to comiucl all operations on thc lcasetmld in accordance with thc
thc lease, lo camiitina all wells for proper abaiidamnent, te re, slate the leased lands upon cnmplctiao of any opctaliaas aa descril~l in th~ lea.sc, ami la furnish and
maiatam such bond as may L,c requ/red hy the tensor pmsuant la regulatimts 43 CFR 3104, 3134. ut 3206.
Far geothermal transfers, an ove, iding royalty may not be less than uae-fourth (i/4) of uae percenl of the value of output, nor graatar dun 50 perch:al of the rate of
royalty duc to thc United States wh~a this assigam:nl is added to all previously created overriding royalties (43 CFR 324 I).
1 certify thai the atat~uncats mad~ herein by me m-e ~, ~mplc~ mid ~rr~t m ~c.~l of my ~owl~ge ~ bclief~ ~ n~¢ in g~ ~.
Name afTr~t~ror ~ shows aa cu[rcmlc~e Richard L. Paterson
Traasferor. ~~
Attorney-ia-fact
P,0, Box 8
Douglas ~ 82633
Public repo~g bmd¢a fo~ ~s fo~ ~ ¢sQmated te ~v¢tage 30 ~u~s ~r r¢s~m¢ iachidiug ~e dam for [eview~g i[~cao~ ga~t~ ~ mammiaiag ~ a~
~mple~ng ~d {¢vtewmg ~ fo~. D~¢cl co~e.~l~ gagging ~c burden astute m ~y uther asl~cl af~is form la U.S. Dcpa~meal of~¢ la~[int, Bm'can afL~d
~g~¢nl ( 1~-~34}. Bmmu CI~ affix, {W~630), ~ Stop 4Ol LS, i M9 C'S~L N.W., W~lm[qo~ DC. 20240.
Richard L. Peterson Trust By:
or Richard L.(S~rson, Trustee
Attorney-m-lkcl
(Sight.e)
Title 18 U.S.C_ Sec. 1001 muk~ il Il clhne tbr any p~un kaawia~ly ami willfuUy m make to any Depazmu:ai ar agency of flu: United Sates any false, lictitious or fraudulcal
statcmcaLs of representations as to any mallcr wltlaa ils jurisdiction.
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