Form B - Transfers And Assignments Of State Leases Statement Of Conveyance

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OFFICE OF MINERAL RESOURCES
STATE OF LOUISIANA
BATON ROUGE, LA
FORM B
TRANSFERS AND ASSIGNMENTS OF STATE LEASES
STATEMENT OF CONVEYANCE
CONVEYOR'S NAME & ADDRESS
EFFECTIVE DATE
LINE #
NAME
GROSS
OF TRANSFER
1
a
STREET
WORKING
(DATE OF SALE)
b
CITY/STATE
INTEREST
c
PHONE NUMBER
d
OWNER'S INTEREST BEFORE CONVEYANCE
e
OWNER'S INTEREST AFTER CONVEYANCE
STATE LEASE
f
INTEREST CONVEYED BY OWNER
NAME & ADDRESS OF TRANSFEREE(S)
2
a
NAME
b
STREET
LEASE ROYALTY DECIMAL
c
CITY/STATE
d
PHONE NUMBER
3
a
NAME
b
STREET
c
CITY/STATE
d
PHONE NUMBER
4
a
NAME
b
STREET
c
CITY/STATE
d
PHONE NUMBER
5
a
NAME
b
STREET
c
CITY/STATE
d
PHONE NUMBER
6
a
NAME
b
STREET
c
CITY/STATE
d
PHONE NUMBER
7
a
NAME
b
STREET
c
CITY/STATE
d
PHONE NUMBER
8
a
NAME
b
STREET
c
CITY/STATE
d
PHONE NUMBER
9
a
NAME
b
STREET
c
CITY/STATE
d
PHONE NUMBER
TOTAL (must equal the amount on line 1f )
PORTION DESCRIPTION:
COMMENTS:
PREPARED BY:
DATE:
Phone Number
formb 9/9/2015
E-mail Address

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