HomeMy WebLinkAbout20121640 NADOA Model Division Order(Adopted 9/95)
YOU R COPY
WELD COUNTY -
Owner: WELD COUNTY COMMISSIONERS Date: 06/18/2012 12:00:00AM
Description: SPEAKER 1-27-31-8-61 7817 JUN 21 P 2: 34 Effective Date: 12/01/2011
Complete Property Description Listed Below
RECEIVED
Production: _X Oil _X Gas Other:
APB- -a5-kab
Owner Name and Address
WELD COUNTY Owner Number: 047962
PO BOX 758 Type Interest: Royalty Interest
GREELEY,CO 80632 Decimal Interest: 0.00075625
Phone Number: 9703564000X4200 FAX Number: 9703520242
Property Description
Property: 2123.01 Speaker 1-27-31-8-61
Operator: CARRIZO OIL&GAS, INC. Location: Weld,CO
Map Reference Information
Weld,CO US Township:008-N Range:061-W Section:27 Lot: Qtr/Qtr:NWNE
292 FNL 1560 FEL
The undersigned certifies the ownership of the decimal interest in production proceeds as described payable by(Payor):
CARRIZO OIL&GAS, INC.
Payor 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.
Payor 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 Payor any amount attributable to an interest to which the undersigned is
not entitled.
Payor may accrue proceeds until the total amount equals$100.00,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 Payor may have certain statutory rights
under the laws of the state in which the property is located.
Owner(s)Signature(s): x - x Sean P. Conway, Chair
UL 02 2012
Owner(s)Tax I.D. Number(s): 84-6000-813 Attest: �i �y
C -rk to B rd
Owner(s)Daytime Phone#: 970-336-7204 B :L�I/i///,
Deputy C1= to the
Owner(s)FAX Number: 970-352-0242
186
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Federal Law requires you to furnish your Social Security or Taxpayer Identification Number.
Failure to comply will result in 28%tax withholding and will not be refundable by Payor. L.£U a-7 -
Carrizo Oil&Gas,Inc. Phone: 713-328-1000
500 Dallas St,Ste.2300 Fax: 713-328-1035
Houston,Texas 77002
Attn: Division Order Department •
DIVISION ORDER/TRANSFER ORDER/DECLARATION OF INTEREST
•
INSTRUCTIONS FOR EXECUTION
Please return one executed original (Division Order/Transfer Order/Declaration of Interest)
Instrument in accordance with the instructions set forth below retaining one copy for your records.
Do NOT alter this document unless the proper documentation is provided supporting the alterations contained
therein. Said documentation must be filed of record in the county/parish(s)where the well is located.
SIGNATURE:
• Sign your name exactly as shown on the Division Order. If your signature is different,legal documentation
supporting the name change is required. If this interest is owned jointly by two or more individuals,ALL
signatures are required unless documentation is provided verifying authorization of one individual to sign
on behalf of all parties.
• Signatures by Agents,Attorneys-in-Fact, Guardians,or Trustees must be verified by attaching a copy of the
recorded legal documentation evidencing of the rights vested in the signatory party.
• In the event of multiple trustees and/or executors,ALL signatures are required unless documentation is
provided verifying authorization of one individual to sign on behalf of all parties.
• Signatures for companies, corporations or partnerships must be executed by an authorized officer with the
name and title of the signatory party printed beneath the signature.
ADDRESS:
• If your address for revenue payments is different from that reflected on the enclosed documentation,please
note the correct revenue payment address ON the Division Order/Transfer Order/Declaration of Interest
TAXPAYER IDENTIFICATION OR SOCIAL SECURITY NUMBER:
• To avoid a 28%withholding tax penalty,as mandated by the.Internal Revenue Code, a Taxpayer
Identification Number or Social Security Number is REQUIRED.
Frequently Asked Questions
(Please keep this for future reference)
What is a division order?
A division order is a directive signed by the royalty owner verifying the purchaser or operator of a well and the
decimal interest of production owned by the royalty owner. Also, it provides the owner's address and tax
identification number(TIN). -
How do I transfer my interest in a property?
Interest may be transferred by a deed or, when appropriate, an assignment The deed or assignment must be
recorded in the county•where the property is located. Carrizo must receive a recorded copy of the deed or
assignment before changing our records and issuing Division Orders. You may want to have an attorney prepare
these documents.
What happens if I change my address or maritaistatus?
Address changes must be received in writing. Please send changes to Carrizo Oil&Gas,Inc.,Attn: Division Order
Department, 1000 Louisiana, Suite 1500, Houston, Texas 77002. Please include your name, old address, new
address, social security number and signature,and if you have been receiving revenue payments your six digit owner
number reflected at the bottom left hand corner of your check detail. Please send a copy of your marriage certificate
to update your name as a result of marriage or a divorce decree if your last name changed due to divorce.
What happens when the interest owner of a property dies? •
After Carrizo is notified the deceased owner's revenue will be held in suspense pending receipt of the proper probate
documents and/or affidavit of death and heirship. Upon notifying Carrizo you will be sent a letter describing what
must be received to transfer the interest of the deceased owner to the appropriate parties and an Affidavit of Death
and Heirship form if necessary.
When are royalty payments suspended?
For your protection,payments are suspended upon a title dispute, assignment of interest,notice of death;transfer of
property, or in the event of no known address. Keeping your information current can prevent this inconvenience.
When will I be paid?
Payments will be made monthly to all owners with cumulative balances of$100 or more. Balances less than $100
will be released in December of each year so that payment is made at least annually.
What do I do if my check is lost,stolen,or becomes outdated?
Please allow (10) business days for your check to arrive in the mail. If your check is lost, stolen or becomes
outdated,please call David Garcia at 713-328-6419 or Eddie Horton at 713-358-6469.
Where can I research unclaimed funds?
Each state makes an effort to locate rightful owners of production revenues through publication, holding the funds
until the owner is found. To locate and collect unclaimed funds,please visit the National Association of Unclaimed
Property Administrators ("NAUPA")website at www.unclaimedbrg. -
What type of annual statements will I receive from your company?
Royalty interest owners receiving more than $10 annually receive IRS form 1099. This summarizes your total
payments and tax withholdings for the previous year.
What state regulatory agency can I contact regarding my property?
TEXAS-Texas Railroad Commission Phone: 512-463-7200 Website:www.RRC.state.tx.us
LOUISIANA Louisiana Office of Conservation Phone:225-342-4500 Website: www.DNR.state.la.bs
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: n�a"%c _t-
�r County Attorney
DATE: 4 --)F---(Z
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