HomeMy WebLinkAbout20111118 •
DIVISION ORDER
TO: Smith Energy Corporation
12706 Shiloh Rd
Greeley, CO 80631 April 15,2011
Each of the undersigned certifies and guarantees that they are the legal owners of, and hereby
warrants title to, their respective interest as set out below in the oil, natural gas, and gas condensate,
produced and saved from the Weld Wetizel 5-33 and 7-33 leases , located in Weld County, State of
Colorado described as:
SW/NW AND NE/SW Section 33,Township 7N, Range 60W
Effective 7:00 a. m. JANUARY 1,2011,and until further written notice,you are authorized and
directed, subject to all of the subsequent provisions hereof,to distribute proceeds as follows for such
products and compliance herewith shall relieve you of any further liability to the undersigned with respect
to such production.
Owner No.0105 Owner Name&Address: Social Security No or Decimal Interest
Weld County Colorado Federal ID No
POBox758 .125
Greeley CO 80532 84-6000-813
The following covenants are part of this division order and shall be binding upon the undersigned,
their successors, legal representatives and assigns:
FIRST: The production received and purchased hereunder shall become the property of the
purchaser designated by you as soon as the same is received into the custody of any such purchaser.
SECOND: The gas received and purchased hereunder shall be delivered f. o. b. any pipe line
designated by the purchaser hereof which gathers and receives said gas, and payment therefore shall be
made to the respective owners according to the division of interest herein specified and at the price and
under the provision of any contract or agreement you may have or make with the buyers of the gas. If any
liquid hydrocarbons are extracted from said gas,the price at which payment shall be made to the respective
owners shall be that which you actually receive for such hydrocarbons and that which you actually receive
for the residue gas.
THIRD: If the Federal Energy Regulatory Commission or other government body having
jurisdiction should subsequently require you to refund a portion of the proceeds derived from the sale of the
oil, gas or condensate received hereunder, each of the undersigned agrees to refund to you his, her or its
proportionate part of such refund.
FOURTH: In the event of any dispute or question at any time concerning title to the above-
described property an/or the oil, gas or condensate produced therefrom, you are authorized to withhold the
proceeds without interest, until such dispute, defect or question of title is corrected or removed to your
satisfaction or until indemnity satisfactory to you has been furnished; and in the event any action or suit is
filed in any court affecting title either to the real property above described or to the oil, gas or condensate
produced therefrom, to which any of the undersigned is a party written notice of the filing of such suit or
action shall be immediately furnished you by the undersigned stating the court in which the same is filed
and the title of such suit or action.
2011-1118
ryt�� Fytyyp L) l'. lr��
5�9/�7�// CV 5-I I -I 1
LE M 1.5
4
FIFTH: The undersigned agree to notify you promptly of any change of ownership affecting their
interest. You will not be responsible for any change of ownership in the absence of actual notice and
satisfactory proof thereof.
SIXTH: This division order may be executed in one document signed by all parties or in separate
counterparts. If executed in separate counterparts, all such, when executed by one or more of the parties,
shall constitute one and the same instrument. This division order shall become valid and binding on each
and every owner above named as soon as signed by him or her regardless of whether or not any of the other
above-named owners have so signed.
ATTEST OWNERS SIGNATURE
C1er to the B.-rd , . La` eldCountyColors o /
BY: i , ►�i ;, MAY 0: 2011
Deputy Cler 'to the B ar `` .n's@O
1161
au�
O VI
do//- ///d'
•
Form 6458
(Rev.June 1985) Certification and Election Form OMB No.15450230
Department of the Treasury
► See separate Instructions. Expires 4-30-88
Internal Revenue Service
Name • Taxpayer identifying number
Weld County, Colorado, Board of County Commissioners 84-6000813
Address(number and street) .
915 10th Street, P.O. Box 758
City or town,state and ZIP code
Greeley, CO 80632 •
Name of purchaser(only completed by a purchaser who s forwarding a qualified disburser election) Taxpayer Identifying number
Part I Exemption Certificate -
I certify that all my production from the properties on the attached list is exempt from the windfall profit tax.
I am entitled to this exemption because I qualify for the status indicated below(check applicable box):
® Qualified governmental interest(section 4994(a)) ❑ Exempt Indian oil(section 4994(d))
❑ Qualified charitable interest(section 4994(b)) 0 Qualified independent producer of exempt stripper well oil(section
4994(g))
I understand that I must file Part III within 10 days after I no longer qualify for exemption from the windfall profit tax.
- Under penalties of perjury. I declare that I have examined this certificate,including accompanying instructions,and to the best of my knowledge and
belief,it is true,correct,and complete.
CHAIRMAN, BOARD OF CO SSIONERS MAY
O 1
1
Signature of exempt producer ► , �i( J/�llC1e1/(y1 Date ► I IA I C L 0 1
Part II Independent Producer Certificate
I certify that I qualify as an independent producer as defined in section 4992, and that all my taxable production from the properties
listed on the attached sheet is entitled to the lower rate of windfall profit tax for tier one and tier two oil.
The total taxable production from these properties (plus production from other qualified properties that I have certified) does not
exceed my share of the 1,000 barrel a day amount for independent producers.
I certify that(check applicable box):
❑ I am a member of a related group(as defined in section 4992(eX2)). I am attaching a list to the Form 6458 that I am filing with the
IRS showing the name and taxpayer identifying number of all other members of my"related group."
❑ !am not a member of a related group(as defined in section 4992(eX2)).
I understand that I must file Part III within 10 days after I no longer qualify as an independent producer.
Under penalties of perjury. I declare that I have examined this certificate,including accompanying instructions, and to the best of my knowledge and
belief,it is true,correct,and complete.
Signature of independent producer ► Date ►
Part III Revocation of a Previously Filed Certificate
I no longer qualify for exemption from,or reduced rates of,the windfall profit tax.The status that I previously claimed was:
❑ Qualified governmental interest 0 Independent producer 0 Qualified independent producer of exempt stripper well oil
❑ Qualified charitable interest ❑ Exempt Indian oil
Date of original certification ► Service Center where filed ►
Effective date of revocation ►
Signature of producer ► Date ►
Part IV Qualified Disburser Election
I certify that I am a qualified disburser as defined in regulations section 51.4995-5(b)and that I hereby elect to perform all the duties normally imposed
upon the purchaser in regard to the administration of the windfall profit tax.
I understand that I must file Part VI within 10 days after this election is terminated.
•
Effective date of electron
Property(include lull lease name,location,and identifying number,if applicable)
Signature of Qualified disburser Date
For Paperwork Reduction Act Notice,see page 1 of the instructions. Form 6458 (Rev.6-85)
Xt/��-/j/U.
•
Form 6458(Rev.6-85) • Page 2
Part V Joint Election for an Operator to Perform All the Duties of the Purchaser
I certify that I am the operator of the property identified below and that I am otherwise required to make deposits of windfall profit tax as a purchaser of
oil from a different reservoir. The purchaser and I hereby elect that I will perform all the duties normally imposed on the purchaser in regard to the
administration of the windfall profit tax.These duties include,but are not limited to.filing quarterly windfall profit tax returns,withholding,making deposits,
and filing annual information returns with respect to this property.
1 understand-that I must file Part VI within 10 days after this election is terminated.
•
Property(include full lease name.location.and identifying number,if applicable)
•
Signature of operator Taxpayer identifying number • Date
I certify that I am the purchaser of oil from the property identified above and that I have transferred all the duties imposed on me by the Crude Oil
Windfall Profit Tax Act of 1980 and its regulations to the operator listed above.
I understand that I must file Part VI within 10 days after this election is terminated..
Signature of purchaser taxpayer identifying number Date
Effective date of election
Part VI Termination of a Previously Flied Qualified Disburser or Joint Operator Election
I hereby certify that the— ❑ qualified disburser election,or ❑ joint operator election,has been terminated(check applicable box).
Property(include full lease name.location.and identifying number.if applicable)
•
Signature of qualified disburser,operator,or purchaser
Date of election Effective date of termination
Service Center where you filed your election
Part Vii Self-Certified Incremental Tertiary Recovery Project
Attached is a certification statement for a qualified incremental tertiary recovery project.The project is certified under the rules contained in regulations
section 51.4993-2(self-certification).
Under penalties of perjury, I declare that I have examined this certificate, including accompanying statements, andito the best of my knowledge and
belief,it is true,correct,and complete.
Signature of petroleum engineer Date
Part VIII Termination of Injection
I hereby notify the Internal Revenue Service that I have ceased injecting liquids,gases, or other matter into&previously self-certified tertiary recovery
project.
Property
Date of seI'certdlcation Service Center where filed
Signature or operator bate
Part IX Jurisdictional Agency Certified Tertiary Recovery Project
Attached is a certification for a qualified tertiary recovery project. The project is certified under the rules contained in regulations section 51.4993-3
(jurisdictional agency certification).
Signature of operator Date
Part X Revocation of a Jurisdictional Agency Certification
I hereby notify the Internal Revenue Service that the jurisdictional agency that previously approved the incremental tertiary project identified below has
revoked that approval.
Protect
bate of revocation -
bate original certification was filed Service Center where fired
Signature of operator Date
a u5. Govvnmmt Printing Ollie: 120—44 1Jas/101aa
•
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/ i
BY: 'f z.51 ountymey
DATE: >S 7 // ,
SMITH ENERGY CORP.
12706 Shiloh Road
Greeley, CO 80631 r-1 l'
(970) 330-7034
(970) 330-2998 FAX
April 15, 2011
Weld County Colorado:
P 0 Box 758
Greeley, Co. 80632
Re: Weld-Weitzel 5-33 & 7--33
Division Order
Weld County Colorado,
Smith Energy Corporation will be dispersing funds on the captioned property.
Please find enclosed a division order and a W-9 Tax form. Please execute the
division order by having your signature witnessed and include your complete
current address and tax identification number.
Return the fully executed division order and the W-9 form to Smith Energy Corp
at the above address.
Very trul ours,
d/Mr-
Robin L. Smith
Enclosures
RECEIVED
APR 18 2011
WELD COUNT Y ASSESSOR
GREELEY, COLORADO
Hello