HomeMy WebLinkAbout20112719.tiff L NADOA Model Form yorti.m.te /9de0 PY
Owner: WELD COUNTY : - Date: 09/19/2011 12:00:00AM
Description: ORLANDO HILL 26-44-8-61 Effective Date: 07/01/2011
Complete Property Description Listed Below
Production: X Oil X Gas Other:
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Owner Name and Address
WELD COUNTY Owner Number. 047962
PO BOX 758 Type Interest: Royalty Interest
GREELEY,CO 80632 Decimal Interest 0.00075625
Phone Number: 9703367215X4226 FAX Number. 9703520242
Property Description
Property: 1894.01 Orlando Hill 2644-8-61
Operator: CARRIZO OIL&GAS,INC. Location: Weld,CO
Map Reference Information
Weld,CO US
The undersigned certifies the ownership of the decimal interest in production proceeds as described payable by(Payor):
Carrizo Oil&Gas,Inc.
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 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.
Owner(s)Signature(s):
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Wald Co y► CO 1
Owner(s)Tax I.D.Number(s): Attest: • ---"^- 84-6000-813
C erk o e Board TIN* Z"'D 1•1'"^^64 r
By
Owner(s)Daytime Phone#: De•u oar. 970-356-4000 X4200
Owner(s)FAX Number. � 970-352-0242
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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. L C O. 4--1G
Carrizo Oil & Gas, Inc.
1000 Louisiana, Suite 1500
Houston, Texas 77002
Attu: Division Order Department
Phone Number: 877-341-2699
Email:LandOwnerRelations(a�crzo.net
DIVISION ORDER INSTRUCTIONS FOR EXECUTION
Please return one executed original (Division Order)Instrument in accordance with the
instructions set forth below retaining one copy for your records.
Do NOT alter this document unless the proper documentation is provided supporting the alterations
contained therein. Said documentation must be filed of record in the county/parish(s) where the well is
locaterl
SIGNATURE:
• Sign your name exactly as shown on the Division Order. If your signature is different, legal
documentation supporting the name change is required_ If this interest is owned jointly by two or
more individuals,ALL signatures are required unless documentation is provided verifying
authorization of one individual to sign on behalf of all parties.
• Signatures by Agents,Attorneys-in-Fact, Guardians, or Trustees must be verified by attaching a copy
of the recorded legal documentation evidencing of the rights vested in the signatory party.
• In the event of multiple trustees and/or executors,ALL signatures are required unless documentation
is provided verifying authorization of one individual to sign on behalf of all parties.
• Signatures for companies,corporations or partnerships must be executed by an authorized officer
with the name and title of the signatory party printed beneath the signature.
ADDRESS:
• If your address for revenue payments is different from that reflected on the enclosed documentation,
please note the correct revenue payment address on the Division Order by crossing thru your old
address and writing in the new one.
TAXPAYER IDENTIFICATION OR SOCIAL SECURITY NUMBER:
• To avoid a 31% withholding tax penalty, as mandated by the Internal Revenue Code, a Taxpayer
Identification Number or Social Security Number is REQUIRED.
SEE THE BACK OF THIS DOCUMENT FOR FREQUENTLY
ASKED QUESTIONS.
FREQUENTLY ASKED QUESTIONS
What is a division order?
A division order is a directive signed by the royalty owner verifying the purchaser or operator of a well and
the decimal interest of production owned by the royalty owner. Also, it provides the owner's address and tax
identification number(TIN).
How do I transfer my interest in a property?
Interest may be transferred by a deed or,when appropriate, an assignment The deed or assignment must be
recorded in the county where the property is located. Carrizo must receive a recorded copy of the deed or
assignment before changing our records and issuing Division Orders. You may want to have an attorney
prepare these documents.
What happens if I change my address or marital status?
Address changes must be received in writing. Please send changes to Carrizo Oil & Gas, Inc., Attn:
Division Order Department, 1000 Louisiana, Suite 1500, Houston, Texas 77002. Please include your name,
old address, new address, social security number and signature, and if you have been receiving revenue
payments your six digit owner number reflected at the bottom left hand corner of your check detail. Please
send a copy of your marriage certificate to update your name as a result of marriage or a divorce decree if
your last name changed due to divorce.
What happens when the interest owner of a property dies?
After Carrizo is notified the deceased owner's revenue will be held in suspense pending receipt of the proper
probate documents and/or affidavit of death and heirship. Upon notifying Canino you will be sent a letter
describing what must be received to transfer the interest of the dernsed owner to the appropriate parties and
an Affidavit of Death and Heirship form if necessary.
When are royalty payments suspended?
For your protection, payments are suspended upon a title dispute, assignment of interest, notice of death;
transfer of property, or in the event of no known address. Keeping your information current can prevent this
inconvenience.
When will I be paid?
Payments will be made monthly to all owners with cumulative balances of$100 or more at the end of each
month. Balances less than$100 will be released in December of each year so that payment is made at least
annually.
What do I do if my check is lost, stolen,or becomes outdated?
Please allow (10)business days for your check to arrive in the mail. If your check is lost, stolen or becomes
outdated,please call David Garcia at 713-328-6419 or Fddie Horton at 713-358-6469.
Where can I research unclaimed fonds?
Each state makes an effort to locate rightful owners of production revenues through publication, holding the
funds until the owner is found To lute and collect unclaimed funds, please visit the National Association
of Unclaimed Property Administrators("NAUPA")website at www.unclaimedorg.
What type of annual statements wall receive from your company?
Royalty interest owners receiving more than $10 annually receive IRS form 1099. This summarizes your
total payments and tax withholdings for the previous year.
What state regulatory agency can I contact regarding my property?
TEXAS—Texas Railroad Commission Phone: 512-463-7200 Website:www.RRC.state.txus
LOUISIANA—Louisiana Office of Conservation Phone: 225-3424500 Website: wwwDNRstate.laus
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:
Cou ty Attorney
DATE: /O-6 -l(
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