HomeMy WebLinkAbout20123260.tiff NPJ1OA Model Form r ivision Order (Arlonted 9/9 1
r% noble DIVISION ORDER
energy
Return To: NOBLE ENERGY, INC Desk Code : CHL 124525
1625 BROADWAY STE 2200 Date : NOV 01 2012
DENVER CO 80202 US Effective Date: MAY 2012
Opera CN
to Name : HERNOBLST LE ENERGYC27-11D INC RP( 65123 .. 3532L0
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 435824925 124102 - 8 0.01654688 RI
% BOAR() OF COUNTY COMMISSIONER
WELD COUNTY CENTENNIAL CENTER
PO 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 month
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 the
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 by
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 the
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 the
property is located.
Special Clauses: RETAIN FOR YOUR RECORDS /9
Owner(s) Signature(s): Sean P . Conway (J`
Owner(s) Tax LD. Number(s): �y�r,/„j,L ,
TIN(s) or SSN(s) 84-6000-813 Attest :
Clerk to t e : oar.I
Owner Daytime Telephone/Fax #: By : // ;� 14 y ���_ ,I ! . O �Deputy Cler to the Boar «
Address Correction . NOV 1 4 2012
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.
2012-3260
LE0131
NOBLE ENERGY.INC. Property Description Attachment
Properly Name : HERBST C27-31 D CN
Operator : NOBLE ENERGY, INC
County/Parish and State : WELD. CO
Property Description
T4N R64W SEC 27:W2NW,SEC 28:E2NE CONTAINING 160 ACRES MORE OR LESS,WELD COUNTY,CO
N 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 on Noble's webpage at http://orms.pds-austin.com/nobleenergy to view or download your detail. If you do not have an
account,please contact PDS Energy at 800-318-7850. Please complete the following:
If you already signed up for direct deposit for this owner number, you DO NOT need to sign up for new
well(s), the first time you sign-up will cover all future well(s).
Type of Application (check one): New ME Change Cancel MIE
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 ME 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 if
(Include SWIFT It 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:
rovaltvrelationsPnobleenerevinc.com
PLEASE ALLOW 90 DAYS FOR THIS REQUEST TO BE COMPLETED.
RECEIVED
NOBLE ENERGY INC.
1625 Broadway, Suite 2200 NOV 0 r, `U.
Denver, Colorado 80202 WELD COUNTY
COMMISSIONERS
November 2,2012
Interest Owner
Re: Property Name : HERBST C27-31D CN
Operator : Noble Energy, Inc.
County/State : Weld, CO
Noble Energy Inc. has successfully completed the above referenced property. First sales occurred June 4, 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.
Chase LaValley
Land Department
720-587-2088
Desk Code: BWB
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