Part A (Continued) ADDITIONAL SPACE for Names and addresses of additional assignees in Item No. 1, if needed, or for Land
Description in Item 2, if needed.
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; as association of such citizens; a municipality; or a corpora-
tion 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 assign-
ment 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 Minerals 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 (f) 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 pertain-
ing 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 true, complete, and correct to the best of my knowledge and belief and are made in
good faith.
Executed this ___________ day of ________________ 20_________ Executed this ___________ day of ________________ 20____
Name of Assignor
(Please type or print)
Assignor
(Signature)
Assignee
(Signature)
or
(Title)
or
(Title)
Attorney-in-fact
(Signature)
Attorney-in-fact
(Signature)
(Assignor’s Address)
(City) (State) (Zip Code)
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, ctitious, or fraudulent statements or representations as to any matter within its jurisdiction.
(Continued on Page 3)
(Form 3000-3, Page 2)
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