HomeMy WebLinkAbout20100865.tiff DIVISION ORDER
Tx: Noble Energy Inc Date: April 1, 2010
1625 Broadway Ste. 2200 Effective Date: First Production
Denver, CO 80202
RETAIN THIS COPY FOR
Well Name: Bashor 17-11
Property Number: 13632 YOUR FILE
Prospect: Weld Cty. Leasing Program - P05166 (DO NOT DETACH EXHIBIT "A")
Operator Petro-Canada Resources (USA) Inc.
County and State: Weld County, Colorado
Property Description: T6N, R63W, 6th P.M., Section 17: N/2NE/4
Production: Oil X Gas X Other
Owner Name and Address: Owner Number: SEE ATTACHED EXHIBIT "A"
SEE ATTACHED EXHIBIT"A" Type of Interest: SEE ATTACHED EXHIBIT"A"
Decimal Interest: SEE ATTACHED EXHIBIT "A"
The undersigned certifies the ownership of their decimal interest in production or proceeds as described on
Exhibit"A" payable by Petro-Canada Resources (USA) Inc. (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 regarding the interest in production
claimed herein by the undersigned.
The undersigned agrees to indemnify and hold Payor harmless from and against any and all liability, loss,
costs, damage and expenses (including, but not limited to, attorneys' fees, court costs and interest at the
statutory prejudgment rate on funds improperly paid to the undersigned), relating to or in any way arising from
from payments made under this Division Order, including payments mistakenly made to the undersigned, or
otherwise attributable to the interest in production claimed by the undersigned. In the event of any mistake in
such payments made to the undersigned, the undersigned shall immediately refund such payments to Payor.
Payor may accrue proceeds until the total amount equals $25.00, or pay once a 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 Payor may have certain
statutory rights under the laws of the state in which the property is located.
Special Clauses: None
Owner(s) Signature: !_( Douglas Rademacher, Chair
04/26/2010
Social Security/Tax ID Numbers) 84-6000-813
Daytime Teiephone No. 970-356-4000 X4200 Witness:
Clerk to the Board
FAX Telephone No. 970-352-0242 Witness:
Deputy Clerk to the Board
Federal Law requires you to furnish your Social Security or Taxpayer Identification Number. �� ,
Failure to comply will result in 31%tax withholding and will not be refundable by Payor. 6s)
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A.� PETRO-CANADA RESOURCES INC
Attached to and made a part hereof that
Certain Division Order
Effective on Date Shown Herein:
Exhibit A
Well/Unit No: 13632 Issue Date: 04/01/10
Well/Unit Name: BASHOR 17-11 Effective Date: First Production
County: WELD Last Change Date: 03/23/10
State: COLORADO O/O Master Ref: 17219
Operator: PETRO-CANADA RESOURCES (USA) I Product: ANY PRODUCT
Original D/O Date: 04/01/10
From Well Master Tract#: 9504
Well/Unit Description:
N/2NE 17-6N-R63W
Owner Owner Name and Address Type Decimal Pay
Number Taxpayer ID Interest Interest Code
102098 WELD COUNTY BOARD OF COUNTY RI 0.00250000 M
COMMISSIONERS
WELD COUNTY CENTENNIAL CENTER
915 10TH ST
GREELEY, COLORADO 80632
PAGE 1
INSTRUCTIONS TO INTEREST OWNERS
This instrument should not be altered in any may unless accompanied by documentary evidence supporting the
change.
If name and interest are correctly shown:
1. Interest owner should sign as shown on the instrument as it reflects record title_ If owner's name has
changed, please alter the Division Order when executing it and attach a copy of the marriage certificate,
divorce decree,change of name certificate or other supporting document.
2. All individual signatures should be witnessed by two disinterested and unrelated parties.
3. For joint interest or life estate interests, execution should include signatures of all joint owners or
remaindermen,as appropriate.
4. If signed by agent, attorney-in-fact, or any party other than the named interest owner, evidence of the
rights vested in the signatory party must be furnished (if not already furnished).
5. All partners must sign for a partnership unless signature is that of an authorized partner, and a certified
copy of his authority must be furnished (if not already furnished).
6 For a limited liability company or similar entity, the signature of the signing party must be duly
authorized by the entity and a certified copy of his authority must be furnished (if not already furnished).
7. If the signature is that of an officer of a corporation, the signature must be attested,title of signatory party
shown and corporate seal affixed.
8. Verify address to which checks are to be mailed and make corrections if necessary. (If a subsequent
chancre of address is necessary, please notify us promptly in writing, including your Owner Number,
which appears on your check).
9. Tax Identification Number or Social Security Number must be inserted in the space provided. The
Internal Revenue Service requires that we withhold 28% of the proceeds payable to any owner who does
not furnish such number. If qualified under Federal Regulation as TAX EXEMPT,copy of Certification of
Tax Exemption should be furnished.
RETURN ONE FULLY EXECUTED INSTRUMENT PROMPTLY TO THE ADDRESS BELOW. KEEP
THE OTHER COPY FOR YOUR RECORDS.
Noble Energy Inc.
Attention: Division Order Department
1625 Broadway,Ste 2200
Denver,CO 80202
•
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.
.7 /
BY✓�GC//4'/LJ. -!
Coufity Attomey
DATE: V-17- /G '
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