Form F Assignment of Lease

OMB Control No. 1076-0180

Expiration Date xx/xx/xxxx

Lease No. _________________

Contract No. ______________

Form F UNITED STATES

DEPARTMENT OF THE INTERIOR

BUREAU OF INDIAN AFFAIRS

OSAGE AGENCY

ASSIGNMENT OF __________ LEASE

WHEREAS, the Secretary of the Interior or his authorized representative has heretofore approved _______ mining lease, dated _________________________________, ____, entered into by and between the ______________ , lessor and _____________________________ __ __, lessee, covering the following-described lands in Osage County, in the State of Oklahoma:

NOW, THEREFORE, for and in consideration of ______ _ __ _____ dollars ($________), the receipt of which is hereby acknowledged, the said _________________________________ the owner of the above-described lease, hereby bargains, sells, transfers, assigns and conveys _______________ __________________ right, title, and interest in and to said lease,

subject to the approval of the Secretary of the Interior or his authorized representative to _____________________________________________________________,of_______________________________________________ . Said assignment to be effective from date of approval by the Secretary of the Interior or his authorized representative.

IN WITNESS WHEREOF, the said assignor has hereunto set ___ hand and seal, this ____

Day of ________ , 20__

Assignor:

By: _________________________

ACKNOWLEDGMENT OF COMPANY

STATE OF

COUNTY OF _________

Before me, a notary public in and for the said county and state on this __ day of ________ , 20___ personally appeared __________________________________________________________________________________________________________ to me known to be the identical person who subscribed the name of the maker thereof to the foregoing instrument as its ________________ and acknowledged to me that he executed the same as his free and voluntary act and deed of such company, for the uses and purposes therein set forth.

_________________________________

Notary Public

My Commission Expires: _______________

ACKNOWLEDGMENT OF INDIVIDUAL

STATE OF ______________________________

COUNTY OF _____________________________

On this _____ day of ___________________, 20_____, before me, a notary public in and for the said county and state, personally appeared _____________________________________, to me known to be the identical person who executed the within and foregoing instrument, and acknowledged to me that _____ executed the same as _____ free and voluntary act and deed for the uses and purposes therein set forth.

__________________________________ My Commission Expires: _______________

Notary Public

ACCEPTANCE BY ASSIGNEE

The assignee in the above and foregoing assignment, made subject to the approval of the Secretary of the Interior, hereby accepts such assignment and agrees to fulfill all the obligations, conditions, and stipulations in said described indenture of lease, when assigned, and the rules and regulations of the Secretary of the Interior applicable thereto, and to furnish proper bond guaranteeing a faithful compliance with said lease and this agreement.

IN WITNESS WHEREOF, the said assignor has hereunto set ____ hand and seal, this _____

Day of _________ , 20__

By: _________________________

Printed Name

Title

CONSENT OF SURETY

The _____________________________________________________, of , surety for on bond accompanying the lease described above, hereby consents to the assignment and transfer of said lease as above made and agrees that said bond shall remain in force and effect covering obligations of Assignee

Dated this _____ day of ______________, 20_____, at ________________________________.

______________________________________

APPROVED: By: ______________________________

______________________________

TO THE ASSIGNOR “This assignment is subject to your contingent liability Department of the Interior

For the payment of any fee, rent royalty, or bonus found to be owing to the Bureau of Indian Affairs

Gov’t during your interest tenure. Your records will continue to be subject to Osage Agency.

Audit for a period of 6 years from approval of this assignment.”

TO THE ASSIGNEE “As of the of this assignment, you assume all liabilities for

fees, rents, bonuses, or royalties owed on this lease. Your books and reports Superintendent

are subject to audit by the Dept. of the Interior to determine your liability for payment.”

“Under authority delegated by 200 DM 1, 209 DM 8, 230 DM 1, 3IAM 4.1 and Muskogee Area Addendum 9901 to 3IAM issued June 22, 1999.

Paperwork Reduction Act Statement: We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to identify assignee who will be responsible for complying with lease. Your response is voluntary and we will not share the results publicly. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a currently valid OMB Control Number. OMB has reviewed and approved this survey and assigned OMB Control Number 1076-0180, which expires ##/##/####.

Estimated Burden Statement: We estimate the form will take you 5 hours to complete, including time to read instructions, gather information, and complete and submit the form. You may submit comments on any aspect of this information collection to the Information Collection Clearance Officer, Office of Regulatory Affairs & Collaborative Action—Indian Affairs (RACA), U.S. Department of the Interior, 1001 Indian School Road NW, Suite 229, Albuquerque, NM 87104.