HomeMy WebLinkAbout20122972 RECEIVED
l . NADOA Model Form Division Order(Adopted 9/9
E�� n DIVISION ORDE
energy WELL) GOUNTY
COMMISSIONERS
Return To: NOBLE ENERGY,INC Desk Coda: YHU 123378
1625 BROADWAY STE 2200 Date: OCT 12 2012
DENVER CO 80202 US Effective Date: JUL 2012
Property Name : GRIGSBY PC AC30-73HN NI
Operator: NOBLE ENERGY, INC
County/Parish and State: WELD, CO
Property Description: Refer to next page for property description attachment
Product: ALL
OWNER NAME PROPERTY# OWNER# INTEREST
WELD COUNTY COLORADO 435820848 124102-8 0.12500000 RI
BOARD OF COUNTY COMMISSIONER
WELD COUNTY CENTENNIAL CENTER
P O BOX 758
GREELEY CO 80632 US
The undersigned certifies the ownership of their decimal interest in production or proceeds as described above payable by Noble Energy,Inc.(Noble).
Noble shall be notified, in writing of any change in ownership decimal interest,or payment address. All such changes shall be effective the first day of the mont
following receipt of such notice.
Noble is authorized to withhold payment pending resolution of a title dispute or adverse claim asserted regarding the interest in production claimed herein by th
undersigned.The undersigned agrees to indemnify and reimburse Noble any amount attributable to an interest to which the undersigned is not entitled.
Noble may accrue proceeds until the total amount equals$25.00,or clear ALL payable proceeds in January of each year,whichever occurs first,or as required t
applicable state statute.
This Division Order does not amend any lease or operating agreement between the undersigned and the lessee or operator or any other contracts for tt
purchase of oil or gas.
In addition to the terms and conditions of this Division Order,the undersigned and Noble may have certain statutory rights under the laws of the state in which th
property is located.
Special Clauses: RETAIN FOR YOUR RECORDS ll
Owner(s)Signature(s): Sean P. Conway, Chair < -7— -
Owner(s)Tax I.D.Number(s): 84-6000-813 0CT 2 2 2012
TIN(s)or SSN(s)
Owner Daytime Telephone/Fax#: 970-336-7204
Address Correction:
Federal Law requires you to furnish your Social Security or Taxpayer Identification Number.Failure to comply will result in tax withholding in accordance with
federal law,which will not be refundable by Payor.
2012-2972
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NOBLE ENERGY,INC. Property Description Attachment
Property Name : GRIGSBY PC AC30-73HN NI
Operator NOBLE ENERGY, INC
County/Parish and Stale WELD, CO
Property Description
T7N R63W SEC 30: E2 CONTANING 320 ACRES MORE OR LESS.WELD COUNTY,CO
NOBLE ENERGY INC.
1625 Broadway, Suite 2200
Denver,Colorado 80202
October 12,2012
Interest Owner
Re: Property Name : GRIGSBY PC AC3e-73HN NI
Operator : Noble Energy, Inc.
County/State : Weld, CO
Noble Energy Inc.has successfully completed the above referenced property. First sales occurred August 25,2012.
According to our records, the interest shown on the attached division order represents your total share of production.
Noble will tender payment to you based upon the stated interest UNLESS you notify Noble,in writing that said interest
is incorrect or that you are not the owner of said interest.
As the owner of the above interest, you shall have the sole liability to notify Noble, in writing, of any address changes
and/or changes in ownership. Until such written notification is received by Noble, payments will continue as
previously described.
Please be advised that Noble does not require a signed Division Order as a prerequisite for payment. This Payment
Letter is intended to replace the traditional division order form and should be retained for your records.
If there are any questions concerning this matter,please contact the undersigned.
Ying Urioste
Land Department
720-587-2128
Desk Code: BWB
noble REVENUE PAYMENT DIRECT DEPOSIT ENROLLMENT FORM
energy
If you are interested in direct deposit, please fill out this form. If you choose direct deposit,you will no longer receive a check or
the detail through the mail.You will receive your detail via email if you provide the information below or you may log into your
account or Noble's webpa„e at http://orms.pds-austin.com/nobleeuergy to view or download your detail. If you do not have an
ccount, please contact PD5 Energy at 800-318-7850. Please complete the following:
If you already signed up for direct deposit for this owner numberjyou DO NOT need to sigh up for new
tvell(s), the firstttime you. sign_uy will cover all future well(s).
Type of Application (check one): New L Change Cancel
Interest Owner Number:
Interest Owner Name:
Tax ID or Social Security Number:
Interest Owner Address:
City, State, and Zip Code:
Daytime Phone Number:
Email Address:
Account for Deposit (check one): Checking Savings
Name(s) on Account:
Financial Institution Name:
Nine (9) Digit Bank Routing Number:
(ABA number)
Account Number:
If the bank is outside the US, please check here: ■ SWIFT#
(Include SWIFTS(if outside the US)
WE CANNOT PROCESS YOUR DIRECT DEPOSIT FORM FOR CHECKING WITHOUT A VOIDED CHECK.
PLEASE ATTACH A VOIDED CHECK TO THIS FORM FOR A CHECKING ACCOUNT.
By signing below, I authorize Noble Energy, Inc.and my bank to electronically deposit my payment to the bank account
specified above. I understand that this authorization will remain in effect until I notify Noble by completing a new Direct
Deposit Enrollment Form canceling or changing my information. Forms may be obtained by contacting Royalty Relations at the
address below. Please sign and return the form. If you have a joint Noble account, both interest owners must sign.
Noble Energy, Inc,
P O Box 909 Signature:
Ardmore, OK 73402
Attn: Division Orders Joint Signature:
Phone: 800-220-5824 Date:
rovaltyrelations@nobleenergvinc.com
PLEASE ALLOW 90 DAYS FOR THIS REQUEST TO BE COMPLETED.
COUNTY ATTORNEY STAFF APPROVAL
This is to affirm the attached Division Order and Authorization to
Receive Payment for an Oil and Gas Well has been reviewed by the
County Attorney's staff as to form, legal description, and percentage
of royalties, if applicable.
BY: ,< �
i<J Cou ty Attorney
DATE: /()-1(.97Z-
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