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NADOA Model Form Division Order(Adopted 9/95)
DIVISION ORDER
To: Weld County Board of Date: December 7, 2010 -(
Commissioners
Property Number: Effective Date: 1st date of productlolP
Property Name: See Exhibit"A" Lease No.:
Operator: Bonanza Creek Energy Operating Company, LLC
County and State:
Property Description:
Production: Oil Gas Other:
Owner Name Weld County 3oard of Commissioners OWNER NUMBER: 1041
And Address: P 0 Box 758
Greeley,CO 80632-0758 Type of Interest: See Exhibit"A"
Decimal Interest: See Exhibit"A"
The undersigned certifies the ownership of their ownership of their decimal interest in production or proceeds as described above
payable by Bonanza Creek Energy Operating Company, LLC (Payor).
(Company Name)
Payor shall be notified, in writing,of any change in ownership, decimal interest,or payment address. As 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 One Hundred Dollars ,or pay N/A 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:
W Id County Board of Commissioners
Owner(s)Signature(s):
Q/,%RI,Q_ /ji(}Jh P-Ap _ Barbara Kirkmeyer, Chair
JAN 03Z011
Owner(s)Tax I.D.Number(s) 84-6000-813 "7-5Owner Daytime Telephone#: 970-356-4000 X4200 Attest: y �
Cler to the Boar ,�
Owner Fax Telephone#: 970-352-0242 By`/�
Deputy Cl- k to t %6:.f} (5„,*
Federal Law requires you to furnish your Social Security of Taxpayer Identification Numb• 1 itto*Failure to comply will result in 31% tax withholding and will not be refundable b Payor.
2011-0022
jo 3
Exhibit"A"
Attached to Division Order dated 12-7-10
Weld County Clerk of the Board of Land Commissioners
Well Name Interest Type Decimal Interest
OK PRONGHORN 12-9 RI I-E03L?, 0.125 SWU/ rau>'a s) 75 ti R '=sw
cE PRONGHORN 14-4 RI / El)?/ ,a 0.0625 S:0Vawy =` T O '(=:d .,-)
PRONGHORN 43-15 RI 65)sI _-
OK WELD COUNTY 22-15 RI LEWitl 0.125 SE9rowu S+L 'rsN 12(.11.0
OK PRONGHORN 34-22 RI -,r__+;?IG, 0.125 Swy 31....,-1 Sae, 75N 4U;a�
OICPRONGHORN31-21 RI LEoa1S 0.125 I1sxl Na'a ' 3` `'3"IF `'
v NORTH PLATTE 31-34 RI LECI7J 0.2 Nu'4 NFu . .-ii ;St ,o
{.t rNORTH PLATTE 41-34 RI L E DI7 3 0.2 !x _-I 7J' Lt 534 T5 ) 1 .
'4
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.
/ 2
BYu� (4i
;J _ � / `////"'C"''o tyAttomey
DATE: /2 2Z —710
/Cr Set 9- T 6 - /2b / 1J
INSTRUCTIONS FOR EXECUTING DIVISION ORDERS
Please verify that your interest, as set out in the Division Order is correct.
Owner Name and Address:
Please verify that the owner name and address to which royalty checks are to be mailed
is correct. If the address is incorrect, please make the necessary changes. Please
include a daytime telephone number.
Owner Name/Sicnature: Two individuals must witness your signature.
Individuals — Please sign name as shown.
Corporation — If signing for a corporation, please print the name of the corporation
and the name and title of signatory party.
Partnership — If signing for a partnership, all partners must sign unless signed by an
authorized partner and a copy of his authority furnished.
Signature by Second Party — If the instrument is signed by an agent, attorney-in-
fact, guardian, estate representative, trustee or any party other than the named
interest owner, evidence of the rights vested in the signatory party must be provided.
If name/ownership is incorrect has changed, or in any way is different from
what is set out on the Division Order,j,/ease provide documentation.
Tax I.D. No.:
Insert social security number/tax identification number in space provided. It is required
by federal law to report this information to the Internal Revenue Service. Your failure
to provide the appropriate social security number or tax identification number will
require Operator to deduct from your revenue payment a federal withholding tax of
31%.
RETURN ONE COPY OF THE EXECUTED DIVISION ORDER IN THE ENVELOPE
PROVIDED
KEEP ONE COPY FOR YOUR RECORDS.
If you have any questions, please contact:
Monica L. Ward-Keller
Bonanza Creek Energy
4900 California Ave., Suite 350B
Bakersfield, CA 93309
Telephone No.: 661-377-3205
Fax No. 661-638-2733
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