HomeMy WebLinkAbout20111450 NADOA Model Form Division Order(Adopted 9/95)
DIVISION ORDER
To: Petroleum Development Corporation Date: June 6,2011
1775 Sherman Street,Suite 3000 •
Denver,CO 80203
Attn:Terah Coffman (303) 860-5805 •
Property Number: 105.100024 Effective Date: January 19,2011
Property Name: P&H 22SD NBCD
Operator: Petroleum Development Corp
County and State: Weld, Colorado
Property Township 5 North,Range 64 West
Description: Section 22:SWNE(spacing S/2NE&N/2SE)
Production: X Oil X Gas X Other: all products
Owner Name OWNER NUMBER: 43444
and Address:
Weld County Brd Of Comm Type of Interest: RI
PO Box 758 Decimal Interest: 0.00285440
Greeley,CO 80632-0000
The undersigned certifies the ownership of their decimal interest in production or proceeds as described above payable by Petroleum
Development Corporation(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 $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: (N ne or See Attache Exhibit)
Owner(s)Signature(s): zu A ,Y_fil.?i. Lti
Barbara Kirkmeyer, Chair
/—Weld County Brd Of Comm/ JUN 1 3 2011
Owner(s)Tax ID(EIN or SSN): 84-6000-813
Owner Telephone(optional):
Owner Email (optional):
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
Ric
Retain this copy for your records
-/3 - IC//
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