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NADOA Model Form Division Order(Adopted 9/95)
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`f DIVISION ORDER
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Return To: NOBLE ENERGY,INC Desk Cod : KCS CL�
1625 BROADWAY STE 2200 2@ft S�: JI
tu:�J I 0 ,/ a(a::� t,e AUG z32o10
DENVER CO 80202 US Effective Date: NOV 2009
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Property Name: WIEDEMAN J 28-21D CN
Operator: NOBLE ENERGY,INC
County/Parish and State: WELD, CO
Property Description: Refer to next page for property description attachment
Product: ALL
OWNER NAME PROPERTY# OWNER# INTEREST
WELD COUNTY COLORADO 435686288 124102-1 0.03125000 RI
C/O BOARD OF COUNTY
COMMISSIONERS WELD COUNTY
CENTENNIAL CENTER PO BOX 758
GREELEY CO 80632 US
The undersigned certifies the ownership of their decimal interest in production or proceeds as described above payable by Noble Energy,Inc.(Noble).
Noble 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.
Noble 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 Noble any amount attributable to an interest to which the undersigned is not entitled.
Noble may accrue proceeds until the total amount equals$25,or pay proceeds with a balance of $10 or more annually in September of each year,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 Noble may have certain statutory rights under the laws of the state in which the
property is located.
Special Clauses:
Owner(s)Signature(s):
Dougla Rade acher, Chair, Board of W•ld County C• rissioners
Owner(s)Tax I.D.Number(s):
TIN(s)or SSN(s) 84-6000-813 Attes : /, ._,__:_�• s
CT to the and
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Owner Daytime TelephonelFax#: 970-356-4000 X4200 Ry: yLcc
� the Bo d
Deputy C1e to .i�
Address Correction: {`11,61 °ea'te,
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Federal 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 Noble Energy,Inc.
2010-2200
LE OCI C1
NOBLE ENERGY.INC. Property Description Attachment
Property Name : WIEDEMAN J 28-21D CN
Operator : NOBLE ENERGY,INC
County/Parish and State : WELD, CO
Property Description
T5N R66W SEC 28:SWNE,SENW,NESW,NWSE
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Dear Interest Owner,
Please read carefully before signing the enclosed oil and gas division orders:
1. Your interest as shown on this instrument should not be altered in any way unless
accompanied by documentary evidence to support the change. We may reject any
division orders changed without our approval. Do not detach Exhibit'A!',if
applicable.
2. Furnish in writing any change of address information and include your signature.
For change in ownership, furnish copies of properly filed and recorded legal
documents affecting title of interest ownership under which payment is made.
Prove a letter describing effect of change.
3. Sign your name EXACTLY AS IT APPEARS ON THE INSTRUMENT.
4. If signing for a corporation, signature must be attested, corporate seal affixed and
title of signatory party shown.
5. If the instrument is signed by an agent, attorney-in-fact, guardian, estate
representative, trustee or any party other than the named interest owner, we must
have evidence of the rights vested in the signatory party.
6. If an interest is shown jointly for more than one person, each party must sign the
division order in the manner that his or her name is shown thereon. In the event
one party has been designated agent for the joint interest shown or he/she has
been granted a power of attorney for the other party(ies), we must have evidence
to this effect.
7. Insert your Tax Identification Number or Social Security Number, whichever is
applicable, in the space provided. We may withhold payment until such number
is received.
8. Confirm the address to which checks are to be mailed. If different, please provide
the correct address. You should notify us promptly of any changes in your
mailing address.
9. Return the executed instrument without delay to the address below. 042
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RETURN SIGNED DIVISION ORDER TO:
NOBLE ENERGY INC.
ATTENTION: MARILYN PEOPLES
1625 BROADWAY, SUITE 2200
DENVER, CO 80202
WITH QUESTIONS OR CONCERNS
REGARDING YOUR DIVISION ORDER
" Vz FAX: (303)228-4287
•
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.
" County Attorney
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DATE: 7 /c//(4
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