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Get DoI 3000-3a 2012

VED OMB NO. 1004-0034 Expires: July 31, 2015 Lease Serial No. 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) Type or print plainly in ink and sign in ink. PART A: TRANSFER 1. Transferee (Sublessee)* Street City, State, Zip Code 1a. Transferor *If more than one transferee, check here separate attached sheet .

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