HomeMy WebLinkAbout20121216.tiff NADOA Model Form Division Order(Adopted 9/95)
DIVISION ORDER
SUNDANCE ,VELD COUNTY
enelgy COMMISSIONERS
Return To: SUNDANCE ENERGY, INC. Property Number: CO1044
633 17th Street, Suite 1950 2011 MAY -9 A II: Ii Date: 5/1/2012
Denver, CO 80202 RECEIVED Effective Date: 3/9/2012
Property Name: Lamb 15C
Operator: Sundance Energy, Inc.
County/Parish and State: Weld County, CO
Property Description: NE/4, Section 15 TAN-R68W 6`" P.M.
Production: n oil n Gas In Other:
OWNER NAME PROPERTY # OWNER # INTEREST
Weld County Commissioners CO1044 1918 RI=0.00150625
1150 O Street, P.O. Box 758
Greeley, CO 80632
OTHER PARTIES REMAINING INTEREST
The undersigned certifies the ownership of the decimal interest in production or proceeds as described above payable by Sundance
Energy, Inc. (Sundance).
SUNDANCE 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.
SUNDANCE 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 SUNDANCE any amount attributable
to an interest to which the undersigned is not entitled.
SUNDANCE may accrue proceeds until the total amount equals $100.00 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 Division Order, the undersigned and SUNDANCE may have certain statutory rights under the
laws of the state in which the property is located.
Special Clauses: NONE
Owner(s)Signature(s): �/�1� -- Attest: CA^� 61,e-"'
Clerk to the Board
Owner(s) Printed Name(s): William F. Garcia, Chair Pro-Tee r""" `"'
Owner(s)Address(s): B :
MAY 1 420 Deputy Clerk/Eo h . ,\,4
Owner(s)TIN(s)or SSN(s): 84-6000-813 V
NTr(17,74r.
«\ 7
Owner(s) Daytime Telephone/Fax#: 970-336-7204 - 970-352-0242 t))
Federal Law requires you to furnish your Social Security or Taxpayer Identification Number,Failure to comply will result
in 31%tax withholding and will not be refundable by SUNDANCE.
Analyst/Asst.:
PLEASE SIGN AND RETURN ONE DOCUMENT TO SUNDANCE ENERGY, 2012-1216
CC,. . 5t.v1diURt (ov x6)
5 a 5 1 a LEp\8')‘
4 RETAIN ONE COPY FOR YOUR RECORDS
Legal Description: „
NE/4, Section 15 T4N-1:168W 6 P.M.
Division of Interest
OWNER NAME PROPERTY # OWNER # INTEREST
Weld County Commissioners
CO1044 1918 R1=0.00150625
1150 O Street, P.O. Box 758
Greeley, CO 80632
^ �J
SUNDANCE WENTY
COMMISSIONERS
energy
May 7, 2012 2011 MAY -9 A II: 11
Weld County Commissioners RECEIVED
1150 O Street, P.O. Box 758
Greeley, CO 80632
RE: CO1044
Lamb 15C
Weld Co. CO
Owner No. 1918
Dear Interest Owner:
Enclosed is a Sundance Energy, Inc. Division Order covering your interest in the captioned property.
Please follow the instructions below to ensure the Division Order is properly executed.
1. Verify your name and address and make any necessary changes.
2. Division Orders for corporations must be executed by an authorized officer
3. As required by Federal law, please provide your Social Security Number and/or Tax
Identification Number in the space provided.
4. Please refer to your owner number above when making inquiries about your payments or your
interest.
A self-addressed stamped envelope is enclosed for your use in returning one fully executed copy of the
Division Order to us. The other copy is for your files.
Sundance issues payments on or about the 15'x'of each Month. Please refer to the Division Order
regarding minimum payments.
If you have any questions regarding your interest or if any of the information is incorrect, please contact
Mr. Ray Pempengco at the above address, you may call (303) 499-6329.
Sincerely
Sun an Ener y nc
Michael M. Wolfe
Senior Land Manager
633 17th Street 32 Beulah Road
Suite 1950 Norwood SA 5067
Denver, CO 80202 `s�ro uh Australia
Office 303 543 5700 H Office +61 8 8363 0388
Fax 303.543.5701 Fax +61 8 8132 0766
w w w.sun d a nc e e n e r g y.net ux w w w.s u n d a n c e e n e rg y.co m.au
ACN 112 202 883
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.
i'
Y: 1 ��
Coun Attorney
DATE: C2 -7?
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