Form 3000-3 Assignment of Record Title Interest in a Lease for Oil a

Form 3000-3
(July 2012)

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, 2015
Lease Serial No.
Lease Effective Date
(Anniversary Date)
New Serial No.

Type or print plainly in ink and sign in ink.
PART A: ASSIGNMENT
1. Assignee*
Street
City, State, Zip Code

1a. Assignor

*If more than one assignee, check here
separate attached sheet of paper.

and list the name(s) and address(es) of all additional assignees on page 2 of this form or on a

This record title assignment is for: (Check one)

Oil and Gas Lease, or

Interest conveyed: (Check one or both, as appropriate)

Geothermal Lease

Record Title,

Overriding Royalty, payment out of production or other
similar interests or payments

2. This assignment conveys the following interest:
Land Description
Additional space of page 2, if needed. Do not submit documents or agreements
other than this form, such documents or agreements shall only be referenced herein.

Owned

Percent of Interest
Conveyed
Retained

Percent of
Overriding Royalty
Similar Interests
Reserved

a

b

c

d

e

Previously
reserved
or conveyed
f

FOR BLM USE ONLY – DO NOT WRITE BELOW THIS LINE
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 effective

Assignment approved for attached land description
Assignment approved for land description indicated
on reverse of this form

By
Bureau of Land Management (BLM)
(Continued on page 2)

(Title)

(Date)

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 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; (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 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 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 as shown on current lease _____________________________________________________________________________________________
(Please type or print)
Assignor

Assignee
(Signature)

or

(Signature)

(Title)

or

(Title)

Attorney-in-fact

Attorney-in-fact
(Signature)

(Signature)

(Assignor’s Address)
(City)

(State)

(Zip Code)

Title 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.
(Continued on page 3)

(Form 3000-3, page 2)

PART C – GENERAL INSTRUCTIONS
1.

2.
3.

4.

5.

6.
7.
8.

9.

Assignor/Assignee must complete Parts A1 and A2 and Part B. All parties to assignment must sign as
follows. The assignor(s) must manually sign 3 original copies and the assignee(s) must manually sign
at least 1 of the 3 original copies. File three (3) completed copies of this form in the proper BLM
office for each assignment of record title. For a transfer of overriding royalty interest, payment out of
production or other similar interest or payment, file one (1) manually signed copy of this form. The
required filing fee (nonrefundable) must accompany the assignment. File assignment within ninety
(90) days after date of execution of assignor.
Separate form must be used for each lease being affected by this assignment and for each type of
interest conveyed.
In Item No. 2 of Part A, describe lands affected (See 43 CFR 3106, 3135 or 3241). For columns b, c,
d, and e, enter the interest expressed as a percentage of total interest in the lease, e.g., if assign or
assigns one quarter of a 20% interest, enter 20% in column b, 5% in column c, and 15% in column d.
If assignment is to more than one assignee, enter each assignee’s name across columns d, e, and f next
to the respective interest being conveyed. Also, list names and addresses of any additional assignee(s)
on reverse of this form or on a separate attached sheet of paper.
If any payment out of production or similar interest, arrangements or payments have previously been
created out of the interest being assigned, or if any such payments or interests are reserved under this
assignment, include a statement giving full details as to amount, method of payment, and other
pertinent terms as provided under 43 CFR 3106, 3135, or 3241.
The lease account must be in good standing before this assignment can be approved as provided under
43 CFR 3106 and 3241.
Assignment, if approved, takes effect on the first day of the month following the date of filing in the
proper BLM office. If a bond is necessary it must be furnished prior to approval of the assignment.
Approval of assignment of record title to 100% of a portion of the leased lands creates separate leases
of the retained and the assigned portions, but does not change the terms and conditions of the lease
anniversary date for purposes of payment of annual rental.
Overriding royalty, payment out of production or other similar types of transfers must be filed with
BLM, but will be accepted for record purpose only. No official approval will be given.

(Continued on page 4)

(Form 3000-3, page 3)

NOTICES
The Privacy Act of 1974 and the regulation in 43 CFR 2.48(d) provide that you be furnished the following
information in connection with information required by oil and gas/geothermal lease record title assignment
application.
AUTHORITY: 30 U.S.C. 181 et seq.; 30 U.S.C. 1001-1025; 42 U.S.C. 6508
PRINCIPAL PURPOSE: The information is to be used to process record title assignments for oil and
gas/geothermal resources leases.
ROUTINE USES: (1) The adjudication of the assignee’s rights to the land or resources. (2) Documentation for
public information in support of notations made on land status, records for the management, disposal, and use of
public lands and resource. (3) Transfer to appropriate Federal agencies when concurrence is required prior to
granting a right in public lands or resources. (4)(5) Information from the record and/or the record will be
transferred to appropriate Federal, State, local or foreign agencies, when relevant to civil, criminal or regulatory
investigations or prosecutions.
EFFECT OF NOT PROVIDING INFORMATION: If all requested information is not provided, the assignment
may not be approved. See regulations at 43 CFR Groups 3100 and 3200.
The Paperwork Reduction Act of 1995 requires us to inform you that:
BLM collects this information to create and maintain a record of oil and gas/geothermal lease activity.
This information will be used to create and maintain a record of oil and gas/geothermal lease activity.
Response to this request is required to obtain benefit.
BLM would like you to know that you do not have to respond to this or any other Federal agency-sponsored
information collection unless it displays a currently valid OMB control number.
BURDEN HOURS STATEMENT: Public reporting burden for this form is estimated to average 30 minutes per
response including the time 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 form to U.S.
Department of the Interior, Bureau of Land Management (1004-0034), Bureau Information Collection Clearance
Officer (WO-630), 1849 C Street, N.W., Room 2134LM, Washington, D. C. 20240.

(Form 3000-3, page 4)