HomeMy WebLinkAbout20123494.tiff NADOA Model Fonn Division Order(Adopted 9/95)
DIVISION ORDER
To: PDC Energy,Inc. Date: November 14,2012
1775 Sherman Street, Suite 3000
Denver,CO 80203
Attn:Terah Coffman (303) 860-5805
Property Number: 105,100538 Effective Date: December 10,2011
Property Name: Stifle 12-6H NB
Operator: PDC Energy, Inc
County and State: Weld, Colorado
Property Township 6 North,Range 64 West
Description: Section 6: SWNW
Production: X Oil X Gas X Other: all products
Owner Name OWNER NUMBER: 43444
and Address:
Weld County Board of Comm Type of Interest: RI
PO Box 758 Decimal Interest: 0.00020300
Greeley,CO 80632-0758
The undersigned certifies the ownership of their decimal interest in production or proceeds as described above payable by PDC
Energy,Inc. (Payor).
Payor shall he 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$50.00. or pay yearly 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 Payor may have certain statutory
rights under the laws of the state in which the property is located.
Special Clauses: (None or See Attached Exhibit)
Owner(s)Signature(s): (j`-'. Sean P. Conway, Chair
Weld County Board of Com DEC 1 1 2.I
•
Owner(s)Tax ID (EIN or SSN): 84-6000-813 Attest ("NA",
Owner Telephone(optional): Clerk to the Board1/42
. G
h ��1 Owner Email (optional):
Deputy Cler to the Boa
y,
Federal Law requires you to furnish your Social Security or Taxpayer Identification Number. ,*z 1 D 14
Failure to comply will result in 28 %tax withholding and will not be refundable by Payc
2012-3494
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Retain this coin for your records
Conse i ID- r LE O3b°I
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INSTRUCTIONS TO ALL INTEREST OWNERS
Dear Interest Owner.
PDC Energy, Inc. has enclosed a Division Order for your execution due to the completion of a new well(s).
The attached document should not be altered in any way except to correct spelling errors, unless accompanied by
documentary evidence to support the change.
If your name and interest are correctly shown:
I. Sign your name as shown on the Division Order.
2. If your name has changed due to marriage or divorce, execute the Division Order using your present name and furnish a copy
of the marriage certificate or divorce decree.
3. If signing for a corporation.signature must be attested,corporate seal fixed and title of signatory party reflected.
4. If signed by agent, attorney-in-fact, guardian or any party other than the named interest owner, a certified copy of the power
of attorney or other evidence of such party's right to sign must be furnished.
5. Your royalty check will be sent to the address listed on the Division Order. Please verify that the address listed is correct. If
there is an error in your address or if your address has changed, please note the correction on the Division Order.
6. The top copy or the"Original" of the Division Order should be returned to the address below. The second copy is for you to
retain for your records.
PDC Energy, Inc.
1775 Sherman Street, Suite 3000
Denver, Colorado 80203
Attn: Terah Coffman
7. Should you have any further questions regarding the enclosed Division Order, please contact Terah Coffman at (303) 860-
5805 or you may call the royalty hotline at(888) 860-5836 and someone will return your call within 48 hours.
8. Please DO NOT DETACH the exhibit from the Division Order or Transfer Order if one is included.
Once we receive your completed form, we will place your interest in line for payment. Please note, however, that all
changes must be received by the I0ih of the month in order for the funds to be released for that current month's revenue
run.
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: b44. „,-
(oufity Attorney
DATE:
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