HomeMy WebLinkAbout20122522.tiff NADOA Model Form Division Order/Adopted 9/95)
i� noble DIVISION ORDER
energy
Return To: NOBLE ENERGY, INC Desk Code: JSO 122600
1625 BROADWAY STE 2200 Date: SEP 04 2012
DENVER CO 80202 US Effective Date: MAY 2012
RECEIVED
Property Name: WALCKER AC17-64RN NI
Operator: NOBLE ENERGY,INC
County I Parish and State: WELD, CO SEP - 7 2012
Property Description: Refer to next page for property description attachment WELD COUNTY
Product: ALL COMMISSIONERS
OWNER NAME PROPERTY# OWNER# INTEREST
WELD COUNTY COLORADO 435825052 124102-8 0.20000000 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 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 , or pay proceeds with a balance of $10 or more annually in September 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:
Owner(s)Signature(s): Sean P. Conway, Chair
-� P 1 72012
Owner(s)Tax I.D.Number(s):
TIN(s)or SSN(s) 84-6000-813 Attest:
ClerkAfro e Qy ;
Owner Daytime Telephone/Fax#: 970-336-7204 By: ��(jZdt ,},
Deputy Clerks o the Boa g1 i
Address Correction
1861111}'4,'"
861 Y 4s
4M ` A
.;
Federal Law requires you to furnish your Social Security or Taxpayer Identification Number.Failure to comply will result in tax withholding in a?Tbr8aalice with
federal law,which will not be refundable by Payor.
2012-2522
Y\S2Vdc ,ri�l4S.`,
C1- i1-1 a IJc`olz lone)
CI-1°4 -la LED/3 q
NOBLE ENFRGY INC. Property Description Attachment
Property Name : WALCKER AC17-64HN NI
Operator : NOBLE ENERGY, INC
County/Parish and State : WELD, CO
Property Description
T7N R63W SEC 17:52,CONTAINING 320 ACRES MORE OR LESS,WELD COUNTY,CO
110 West Broadway 1 . noble
Ardmore,OK 73401 L.:4 energy
Tel:580.223.4110
Fax:580.221.1364
www.nobleenergyinc.com
Dear Interest Owner:
Enclosed are copies of Noble Energy, Inc.'s Division Orders for your approval and execution. For
your convenience, Noble has adopted the NADOA Model Form of Division Order.
The purpose of this division order is to provide you information about your ownership and obtain
Certification from you that you are the correct person to whom payments for this interest should be
made.
Please review your decimal interest in the property described. Also review the terms of the division
order.
Supply and/or verify your Social Security or Tax Identification Number. Failure to comply will result in
a tax withholding for the Internal Revenue Service.
Supply and/or verify the address to which checks should be mailed.
The well RC number will be listed on your check detail identifying your payment for this interest. Your
party number is your identifying number with our company. Please refer to this number when
making inquiries about payments or your interest.
After your review of the enclosed division orders, please execute one copy and return to this office
for further handling. The extra copy is for your files.
Please be advised, Noble Energy, Inc. does not accept altered Division Orders. Therefore, if our
division order has been altered, Noble Energy, Inc. will.still make disbursements based on the
ownership and interest stated on our division order, unless otherwise advised in writing.
Individuals-Sign your name as it appears on the Division Order.
Joint Ownership-Should be signed by all owners shown on the Division Order.
Corporations-The name of the Corporation as well as the name and title of the person signing
the document must be included.
Signature by other than named owner-If the Division Order is signed by an agent, attorney-in-
fact, guardian, trustee or any party other than the named owner, please provide a copy of the
document which authorizes him/her to sign on behalf of the owner.
Please note that the interest stated on the Division Order reflects your total owned ownership. However,
Noble Energy, Inc. may or may not disburse 100% of the proceeds.
If you should have any questions, please contact the Division Order Department at the above address.
Sincerely,
NOBLE ENERGY, INC.
Division Order Department
Note: If you would like to have your proceeds electronically deposited to your bank account, please
complete and return the enclosed direct deposit ACH Enrollment Form.
IF YOU HAVE PREVIOUSLY COMPLETED AND RETURNED
THE DIRECT DEPOSIT ENROLLMENT FORM, PLEASE DO NOT RESEND.
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:
Co d my Attorney
DATE: 9'/U i
Hello