HomeMy WebLinkAbout20123468.tiff NADOA Model Form Division Order (Adopted 9/95)
DIVISION ORDER
To: Bonanza Creek Energy Inc. Date: December 3, 2012
410 171° Street Suite 1400
Denver, CO 80202
Attn: Susan Merezko
RECEIVED
Property Number: CO007210 Effective Date: April 1 , 2012
Property Name: NORTH PLATTE P-T-34HZ DEC 0 3 2632
Operator: Bonanza Creek Energy Operating
County and State: Weld, Colorado WELD COUNTI'
Property COMMISSIONERS
Description: Township 5N, Range 63W, Section 34
Production: X Oil X Gas X Other: all products
Owner Name and Address: OWNER NUMBER: 1041
WELD COUNTY BOARD OF COMMISSIONERS Type of Interest: RI
P O BOX 758 Decimal Interest: 0.07500000
GREELEY, CO 80632-0758
The undersigned certifies the ownership of their decimal interest in production or proceeds as described above payable by Bonanza
Creek Energy Inc. (Payor).
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 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): c } 61).
WELD COUNTY BOARD OF MISSIONERS �t1 (1F�„ 0r�,�� Iq
Owner(s) Tax I.D. Number(s): 84- 6000-813 Attest : 1Jp/ ' '� a M1V ed
CleS to the Bo . d
Owner Daytime Telephone 970-336-7204 BY : Aai,.�7r t� p�"�
Owner FAX Telephone #: 970- 192-0747 Deputy Cl • to the Bo f'- Ire /lda
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 Payor t%61
SNM An
Sign and return this original 1M
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i� 2012-3468
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INSTRUCTIONS TO ALL INTEREST OWNERS
Dear Interest Owner,
Bonanza Creek Energy Inc. has enclosed a Division Order for your execution.
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:
1. 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.
4. If signing for a corporation,signature must be attested,corporate seal fixed and title of signatory party reflected.
5. 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 fumished.
6. Your correct mailing address should be noted in the space provided to insure prompt receipt of production proceeds.
7. The top copy or the"Original"of the Division Order should be returned to:
Bonanza Creek Energy Inc.
41017th Street Suite 1400
Denver,Colorado 80202
Attn: Susan Merezko
8. Should you have any further questions regarding the enclosed Division Order,please contact Bonanza Creek Energy at(720)
440-6177.
9. Please DO NOT DETACH the exhibit from the Division Order or Transfer Order if one is included.
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 : ,4 kit � t
jizx County Attorney
DATE : /247b
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