HomeMy WebLinkAbout20120034.tiff ADOA Model Form Division Order(Adopted 9/95)
.l`BAYSWATER DIVISION ORDER
EXPLORATION&Paooucnons,LLC ! COUNTY
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RETURN To: BAYSWATER EXPLORATION&PRODUCTION,LLCj-�'I zr'If•‘CS10NEUTE:12.19.1 1
730 17TM ST.,#610
DENVER,CO 80202.3529 Lu1�ac 21 Q O 22
PROPERTY NAME: WELD COUNTY Gu
PROPERTY#: 9-28,16-28,20-28 r•fir�}j Cfl'E DATE:DATE OF FIRST PRODUCTION
OPERATOR: BAYSWATER EXPLRATION&PROS 19fRLl. .
COUNTY/STATE: WELD,COLORADO
PRODUCTION: XM OIL 0 GAS 0 OTHER:
OWNER NAME&ADDRESS OWNER# TYPE OF DECIMAL
INTEREST INTEREST
BOARD OF WELD COUNTY COMMISSIONERS RI 0.1
915 10TH ST,PO BOX 758
GREELEY,CO 80632
PROPERTY DESCRIPTION:f526W
SE"/ S X18-T'7N-kb't
The undersigned certifies the ownership of the decimal interest in production or proceeds as described above payable to Bayswater E&P,
LLC(Bayswater).
Bayswater 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.
Bayswater 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 Bayswater any amount attributable to
an interest to which the undersigned is not entitled.
Bayswater may accrue proceeds until the total amount equals$ 25.00 or pay annually,whichever occurs first or as required by
applicable state statutes.
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 Transfer Order,the undersigned and Bayswater may have certain statutory rights under the
laws of the state in which the property is located. WOO,{ J,' a
SPECIAL CLAUSES: 2I�
CIN q�Z$ API 05-123-
Weed&hi No-)8 i1Pl 05-Ig3-3,34{21(0
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OWNER SIGNATURE: JAN 0 4 2012 Watt C 20 Z AP1 06-123-34?
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OWNER NAME: Sean P. Conway, Chair
OWNER ADDRESS: P.O. Box 758 1150 0 Street, Greeley, Colorado 80632
OWNER TIN: 84-6000-813
OWNER PHONE/FAX 970 P:356-4000 F: 352-0242
FEDERAL LAW REQUIRES YOU TO FURNISH YOUR SOCIAL SECURITY OR TAXPAYER ID.FAILURE TO COMPLY
WILL RESULT IN 28%TAX WITHHOLDING AND WILL NOT BE REFUNDABLE BY BAYSWATER.
PLEASE SIGN AND RETURN ORIGINAL-RETAIN ONE COPY FOR YOUR RECORDS
O uW .X515 uc-kEr 2012-0034
�-G,-1 LEON:�
.` BAYSWATER
EXPLORATION AND PRODUCTION, LLC
Re: Division Order and Instructions
Dear Interest Owner:
As you are probable aware, Bayswater Exploration and Production, LLC has established
production for the above referenced well for which you may already be receiving revenue
payments.
If you own a royalty interest in this well, the net revenue interest shown on your division order
is calculated by multiplying the royalty interest provided for in your lease by your net acres,
divided by the total acres in the unit, shown above.
In this regard, please find enclosed our division order covering the well, in duplicate, for your
review and execution. Please confirm that the information contained in the division order is
correct and execute the division order in accordance with the sheet of instructions that is
included. Please return one original division order to us. The other copy is for your records.
Upon receipt of the executed division order, your interest will be placed in a pay status.
Please note that failure to provide us a valid tax identification number may result in 31%
withholding that will not be refunded.
If you have any questions or concerns, don't hesitate to contact us.
Sincerely,
Ben Schuessler
720.881.4489
730 17TH STREET. SUITE 610 • DENVER, CO • 80202
PHONE: 303.893.2803 • FAX'. 303.893.2508
BAYSWATER
. EXPLORATION AND PRODUCTION, LLC
INSTRUCTIONS TO ALL INTEREST OWNERS
READ CAREFULLY BEFORE SIGNING DIVISION ORDERS.
FAILURE TO COMPLY WITH THESE INSTRUCTIONS WILL DELAY PAYMENT. THE
ATTACHED DIVISION ORDER SHOULD NOT BE ALTERED IN ANY WAY UNLESS
ACCOMPANIED BY DOCUMENTARY EVIDENCE TO SUPPORT THE CHANGE.
The enclosed Division Order includes a description of the real property, name and address of
interest owner, as well as the type and amount of interest owned. One copy of the Division
Order is to be returned to Bayswater Exploration & Production at the address shown below
and the second copy is to be retained by you for your records. In order to eliminate the
possibility of delayed payments and further correspondence, please follow the instructions
outlined below.
Signature:
Individuals
Sign name as shown on the instrument.
Corporations
If signing for a corporation, signature must be attested, corporate seal affixed, and title of
signatory party shown.
Partnership
Where one member of a partnership signs; evidence of his right to do so must be furnished.
Signature by Second Party
If the instrument is signed by an agent, attorney-in-fact, guardian, estate representative,
trustee or any party other than the named interest owner, evidence of the rights vested in the
signatory party must be provided.
Taxpayer ID or Social Security Number
Without social security or tax identification number your revenue payment will be subject to
31% withholding under IRS Regulations, which is not recoupable from Bayswater Exploration
& Production, LLC.
Address Change
You should notify Bayswater Exploration and Production, LLC in writing as soon as possible
when your mailing address changes. For your protection, Bayswater will not accept address
changes by telephone.
730 17T" STREET. SUITE 610 • DENVER. CO • 80202
PHONE: (303) 893.2503 • FAX: (303) 893.2508
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: M
SkCounty Attorney
DATE: /.2 - 2 — I(
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