Assignment Summary
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1Texas General Land Office
Texas General Land Office
Mail to:
ASSIGNMENT SUMMARY
F
or General Land Office Use Only
Attn: Energy Resources
P.O. 12873
Austin, Texas 78711-2873
DOCUMENT TYPE:
ASSIGNMENT FEE: $25 per State Lease (additional $25 after 90 days)
(mark one):
Assignment
Deed of Trust
Merger/Name Change
INTEREST BEING CONVEYED
: (mark one)
:
DOCUMENT RECORDING INFORMATION
(Include all the counties
Working Interest:
Overriding Royalty Interest:
Other (explain):
covered by the properties listed below)
County
Volume
Page
Execution Date/Effective Date
Remarks:
FROM
TO
% GROSS WI
% GROSS WI
% GROSS WI
List all companies or individuals listed in this instrument
List all companies or individuals listed in this instrument
OWNED BY
TRANSFERRED
RETAINED
who are transferring ownership interests, in whole or in
who are receiving ownership interests in the leases listed
ASSIGNOR
BY ASSIGNOR
BY
part, in the leases shown below
below
ASSIGNOR
1.
2.
3.
4.
Attach additional pages as needed.
LEASES COVERED BY THIS TRANSFER:
State Lease #
COUNTY
BLOCK
SECTION
PART OF SECTION
DEPTH RESTRICTION
1.
2.
3.
4.
Preparer’s Signature
Title
Company Name
____________________________________________________
Name (please print)
Date
Mailing Address
am an authorized representative of the
I
lessee(s) under the State of Texas leases
E-Mail Address
identified herein and represent and certify to the
Commissioner of the General Land Office that
Telephone Number
City/State/Zip
the information provided on this form is true
and correct.
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