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DIVISION ORDER
To: Petro -Canada Resources (USA) Inc.
999 18th Street, Suite 600
u Denver, CO 80202-1904
II Name:
Property Number:
Prospect:
Operator:
County and State:
Property Description:
Production: Oil
Wilson 18-12
16536
Weld Cty Leasing Program - P05166
Petro -Canada Resources (USA) Inc.
Weld County, Colorado
Date:
Effective Date:
June 8, 2009
First Production
RETAIN THIS COPY FOR
YOUR FILE
(DO NOT DETACH EXHIBIT "A")
T6N, R63W, 6th P.M., Section 18: W/2NE
X
Gas
X
Other
Owner Name and Address:
SEE ATTACHED EXHIBIT "A"
Owner Number: 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:
Social Security/Tax ID Number(s)
6(e? -
84-6000-813
William F. Garcia, Cha
Daytime Telephone No. 970-356-4000 X4200 ATTEST:
FAX Telephone No. 970-352-0242
BY:
Clark to thtl:oa
Deputy Clerk%to"the B
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.
°ere 49e
LEoa� o
/1-/7
PETRO-CANADA RESOURCES INC
Attached to and made a part hereof that
Certain Division Order
Effective on Date Shown Herein:
Well/Unit No: 16536 Issue Date:
Well/Unit Name: WILSON 18-12 Effective Date:
County: WELD Last Change Date:
State: COLORADO D/O Master Ref:
Operator: PETRO-CANADA RESOURCES (USA) I Product:
Original D/O Date:
From Well Master Tract#: 11954
Well/Unit Description:
W2NE SEC 18 6N -63W
06/08/09
First Production
04/03/08
15523
ANY PRODUCT
Owner
Number
Owner Name and Address
Taxpayer ID
102098 WELD COUNTY BOARD OF COUNTY
COMMISSIONERS
WELD COUNTY CENTENNIAL CENTER
915 10TH ST
GREELEY, COLORADO 80632
PAGE 1
Type Decimal Pay
Interest Interest Code
RI 0.00125000 M
1
BEATTY & WOZNIAK, Y.C.
Petro -Canada Resources (USA) Inc.
December 8, 2008
Page 61
Mary Lee Hardy
Tract No. 9 (0.585834%NRI x 6.3500%TP)
Dakota G. Rathbun
Tract No. 15 (0.585938%NRI x 4.7500%TP)
Judith M. Millington
Tract No. 8 (0.018750%NRI x 43.8375%TP)+
Tract No. 9 (0.018750%NRI x 6.35(10%TP)f
Tract No. 10 (0.018750%NRI x 6.4750%TP)+
Tract No. I 1 (0.018750%NRI x 6.3500%1'P)+
Tract No. 12 (0A 18750%NRI x 6.4375%TP)+
Tract No. 13 (0.018750%NRI x 7.0375%TP)+
Tract No. 14 (0.018750%NRI x 7.4875%TP)+
Tract No. 15 (0.018750%N RI x 4.7500% P)
0.00037200
0.00027832
0.00016636
Day Mobile Homes, Inc. 0.00100000
Tract No. 16 (16.666700°%NRI x 0.6000%TP)
TOTAL:
1.00000000 1.00000000
Ill. EFFECTIVE AS OF AUGUST 29, 2008
OWNERSHIP OF OIL AND GAS, AND TIIE PROCEEDS FROM THE SALE
OF OIL AND GAS, FOR A 160.00 ACRE DRILLING AND SPACING UNIT
COMPRISING THE NE/4 OF SECTION 18 IN TOWNSHIP 6 NORTH,
RANGE 63 WEST, 61° P.M. (TRACT NOS. 1-17):
, I'.f.IAf rat"rz,' e( 1„I�'';l i,( (NMI !<','Il'1 l.: 1,(. f�. . �(.a
The tract participation percentages for this Division of Interest and Distribution of
Production Proceeds are as follows:
DIVISION OF
INTEREST TRACT TOTAL TRACT
TRACT NO.: ACREAGE: ACREAGE: PARTICIPATION:
2
3
4
6
6.04
4.76
16.59
2.00
44.00
1.59
160.00
160.00
160.00
160.00
160.00
160.00
3.7750%
2.9750%
10.3687%
1.2500%
27.5000%
0.9937%
•
BEATTY & WOZNIAK, P.C.
Petro -Canada Resources (USA) Inc.
December 8, 2008
Page 62
7
8
9
10
11
12
13
14
15
16
* 17
Owner
13.06
35.07
5.08
5.18
5.08
5.15
5.63
5.99
3.80
0.48
0.50
160.00
160.00
160.00
160.00
160.00
160.00
160.00
160.00
160.00
160.00
160.00
8.1625%
21.9187%
3.1750%
3.2375%
3.1750%
3.2188%
3.5188°A
3.7438%
2.3750%
0.3000%
0.3125%
160.00 100.0000`%
Petro -Canada Resources (LISA) Inc.
'tract No. 3 (I 00.0000%WI x 103687%'Ii') i
Tract No. 4 (100.000000%W I x I .2500%'tP) t
Tract No. 7 (40.625000%WI x 8.1625%111F
Tract No. 8 (40.625000%WI x 21.9187%iP)+
Tract No. 9 (40.625000%Wl x 3.1750%TP)t
Tract No. 10 (40.625000"/oWl x 3.2375%tP)+
Tract No. I I (45.312500%WI x 3.1750%/orP)+
Tract No. 12 (45.312500%Wl x 3.2 188%TP)f
Tract No. 13 (40.625000% W I x 3.5188%lP)+
Tract No. 14 (40.625000%WI x 3.7438%TP)+
Tract No. IS (40.625000%WI x 23750%"I'P)I
Tract No. 16 (100,000000%WI x 0.3000%I'P)
Working Net Revenue
Interest Interest
0.33556731 0.27907527
BEATTY & WOZNIAK, P.C.
Pctro-Canada Resources (USA) Inc.
December 8, 2008
Page 69
Tract No. 13 (0.520834%NRI x 3.5188%TP)+
Tract No. 14 (0.520834%NRI x 3.7438%TP)+
Tract No. 15 (0.520834%NRI x 2.3750%TP)
Darlene Wilder Bower
Tract No. 7 (0.468750%NRI x 8.1625%TP)
Tract No. 8 (0.468750%NRI x 21.9187%TP)+
'tract No. 9 (0.468750%NRI x 3.!750%?)'
Tract No. 10 (0.468750%NRI x 3.2375%TP)+
Tract No. 1 I (0.468750%NRI x 3.1750%TP),-
Tract No. 12 (0.468750%NRI x 3.2188%PP)+
Tract No. 13 (0.468750%NRI x 3.5188%'I'P)+
'tract No. 14 (0.468750%NRI x 3.7438%%'IP)+
'tract No. 15 (O,4687511%NRI x 2.3750%'I'P)
Donald Whiteley
Tract No. 5 (0.781250%NRI x 27.5000%TP)+
Tract No. 6 (0.78!250%NRI x 0.9937%I'P)
LeRoy Whiteley, a/k/a/ Lee Whiteley
Tract No. 5 (0.781250%NRI x 27.5000%]P)+
Tract No. 6 (0.781250%NRI x 0.9937%TP)
Donald Lurie
Tract No. 4 (16.666700%NRI x 1.2500%TP)
Heirs or Devisees of Joseph Franklin
Grashot, deceased (unleased minerals)
Tract No. 6 (16.666667%WI x 0.9937%1?)
Tract No. 6 (16.666667%NRI x 0.9937%TP)
0.00246211
0.00222606
0.00222606
0.00208334
0.00165617 0.00165617
JLW Investment, LLC (unleased minerals) 0.00132493
Tract No. 6 (13.333332%Wl x 0.9937 IP)
Tract No. 6 (13.333332%N RI x 0.9937%TP)
*Weld County, OeaSed - 201° 0,.t)
Bd. of Cty. Commr's (�
Tract No. 17 (100.000000%WI x 0.3125%T P)
Tract No. 17 (100.000000%NRI x 0.3125%l'P)
Lynette Disheroon
Tract No. 5 (0.390625%NRI x 27.5000%'TP)+
Tract No. 6 (0.390625%NRI x 0.9937%TP)
a1
0.00312500-
0.00132493
• DOov?.S
0.00312500
0.001 1 1303
Stephanie Arries
From: Smith, Aubrie [ausmith@suncor.com]
Sent: Tuesday, October 27, 2009 2:28 PM
To: Stephanie Arries
Subject: RE: New Well Division Order: Wilson 18-15; Property No 13326
Attachments: Weld Cty Lease - 6N63WSec18.pdf
Ms. Arries,
I apologize for the delay. Attached is a copy of the lease agreement with Petro -Canada that covers the
referenced property.
I'll will pull the title opinion sections and send them over to you as soon as possible.
Hopefully this will help for now.
Thank you.
Aubrie Smith
Jr. Division Order Analyst
Petro -Canada Resources (USA) Inc.
a Suncor Energy Business
Tel: 303-350-1226
Fax: 303-297-7708
ausmithasuncor.com
From: Stephanie Arries [mailto:sarries@co.weld.co.us]
Sent: Tuesday, October 27, 2009 2:16 PM
To: Smith, Aubrie
Subject: FW: New Well Division Order: Wilson 18-15; Property No 13326
Dear Ms. Smith:
As you can see from the previous message, it has been some time since I sent my earlier request and I have not heard
from you.
Would you please check to confirm Weld County's interest in the well? If you have an excerpt from the attorney's title
opinion to send to us, (a scanned version is fine) that would be a very quick way to deal with this.
Your assistance in this matter is greatly appreciated.
Stephanie L. Arries
Assistant Weld County Attorney
915 Tenth Street
P.O. Box 758
Greeley, Colorado 80632
Tel: 970-356-4000 ext 4394
Fax: 970-352-0242
Email: sarries@co.weld.co.us
STATEMENT OF C' Ni . 1)ENTJAt,1'1'y & DISCLAIMER: The information contained in this email
message is atterey privileged and confidential, intended only for the use of the
individual or entity named above. If the reader of this message is not the intended
recipient, you are hereby notified that any dissemination, distribution or copy of this
email is strictly prohibited. If you have received this email in error, please notify us
immediately by replying and delete the message. Thank you.
1
From: Stephanie Arries
Sent: Tuesday, June 30, 2009 3:04 PM
To: 'Aubrie.Smith@petro-canada.com'
Subject: New Well Division Order: Wilson 18-15; Property No 13326
Dear Ms. Smith:
I am writing to you concerning the above -referenced matter.
In a letter dated June 11, 2009, you requested the Board of County Commissioners of Weld County to execute a division
order for the well described above. The office of the Clerk to the Board maintains the files for the properties held by the
County. However, there is no file on the property you describe as "T6N, R63W, 6th P.M., Section 18:NE".
Therefore, the Board would need some information from you to verify that the County is entitled to the interest you
describe. Would you please forward either an excerpt of a title opinion upon which you are relying, a copy of a lease
agreement, or whatever else you have that reflects the County's entitlement? Upon our receipt of one or more of the
foregoing documents, the Board will expeditiously execute the Division Orders, and send one original to you.
Your assistance in this matter is greatly appreciated.
Stephanie Arries
Stephanie L. Arries
Assistant Weld County Attorney
915 Tenth Street
P.O. Box 758
Greeley, Colorado 80632
Tel: 970-356-4000 ext 4394
Fax: 970-352-0242
Email: sarries(a)co.weld.co.us
STATEMENT OF CONFIDENTIALITY & DISCLAIMER: The information contained in this email
message is attorney privileged and confidential, intended only for the use of the
individual or entity named above. If the reader of this message is not the intended
recipient, you are hereby notified that any dissemination, distribution or copy of this
email is strictly prohibited. If you have received this email in error, please notify us
immediately by replying and delete the message. Thank you.
or, email and tl: r tint .its are private and confidentialfor the sole use of the addresseesif you are not an intended recipientcopyingforwarding or other
distr but on of Its"; email or its contents by any means io prohibited If you behove that you received this email in error please notify the original sender immediately.
Petro -Canada is a Suncor Energy business,
Ce courtlet et son content sent prives et confdentiels, et sent destines a I usage exclusif des destinataires. Si vows n'etes pas le destinataire prdvu, toute
reproduction, tiansfer on antic forme de diffusion de ce courtier ou de son contenu par quelque moyen due ce soit est interdit. Si vous creyez avoir requ co
rourrlel par erreurveuillez en aviser I'expediteur original immediatetnent.
Petro -Canada est une untruly [so de Suncor Energie.
2
Pell]
PETROCANADA, Petro -Canada Resources (USA) Inc.
/e //
( /f(
June 11, 2009
TO: Interest Owners
Re: NEW WELL DIVISION ORDER(S)
Weld County, CO
Ladies and Gentlemen:
Petro -Canada Resources (USA) Inc. (as "OPERATOR") has drilled the producing well as referenced in
the enclosed Division Order in which you own an interest. To complete our records, please follow the
procedures on the enclosed Instruction Sheet and return one (1) fully executed Division Order to my
attention in the postage paid envelope. The second original is for your files. NOTE: If you are currently
not being paid on this well, upon receipt of the executed Division Order, your interest will be released.
Also enclosed you will find a standard W-9 Request for Taxpayer Identification form. Petro -Canada is now
required to have complete and correct tax payer information on file for all persons and/or companies
receiving payments regardless of their tax status. Along with your executed Division Order, we respectfully
request you sign and promptly return this W-9 form. It is important to note that failure in returning this
document could lead to the delay in processing revenue distributions for your account.
If you should have any questions or concerns, please do not hesitate to call me at 303-350-1226 or at the
e-mail address below. Thank you for your cooperation to our request.
/ams
Enclosure
Sincerely,
PETRO-CANADA RESOUR ES (USA) INC.
itki-Xl—Qc (At
Aubrie M. Smith
Jr. Division Order Analyst
Aubrie.Smith(C7petro-canada.com
IT:
C
C)
Ul
Suite 600, 999 18th Street • Denver, CO 80202
Office: (303) 297-2100 • Fax (303) 297-7708 • www.petro-canada.ca
INSTRUCTIONS TO INTEREST OWNERS
This instrument should not be altered in any way 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
change 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 31% 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.
NEW ADDRESS EFFECTIVE 11/26/07
Petro -Canada Resources (USA) Inc.
Attention: Aubrie Smith
999 18th Street, Suite 600
Denver, CO 80202-2499
Direct Telephone Number: 303-350-1226
Main Telephone Number: 303-297-2300
FAX Telephone Number: 303-297-7708
Checks will be issued by our accounting department monthly upon receipt of the fully executed Division Orders.
However, funds will be held until the account totals $25.00 and/or on an annual basis.
POLITICAL SUBDIVISION SALES TAX EXEMPTION CERTIFICATE
(For use by States, Territories, or Political
Subdivision thereof, or the District of Columbia)
The undersigned hereby certifies that she is the Controller of Weld County Government and that she is
authorized to execute this Certificate and that all taxable articles/services purchased from
are for the exclusive use of Weld County Government, State of Colorado.
It is understood that the exemption from tax in the case of sales of articles under this Exemption
Certificate to the State, Territory, or Political Subdivision or District of Columbia is limited to the sale of
articles purchased for their exclusive use, and it is agreed that if articles purchased tax-free under this
Exemption Certificate are used otherwise or are sold to employees or others, such fact must be reported
to the manufacturer of the articles covered by this Certificate. It is also understood that the fraudulent use
of this Certificate to secure exemption will subject the undersigned and all parties making use of this
Certificate to all applicable criminal penalties under the Internal Revenue Code.
COLORADO SALES TAX CERTIFICATION OF EXEMPTION NUMBER - 98-03551
FEDERAL TAX EXEMPTION NUMBER - 84-6000813
STATE TAX IDENTIFICATION NUMBER - 14-02101
Sales to the United States government old to the State of Colorado, its departments and institutions, and its political subdivisions
(cities, counties, school districts, state higher education institutions and special taxing districts) are exempt (from paying sales tax) by
statute. (39-26-704.1 C.R.S.]
Some governmental entities have a Coloradoissued tax -exemption number, although they am not required to have one. Following
is a copy of Weld County Govemment'smost recent Colorado -issued Certificate of Exemption for Sales and Use Tax Only.
CERTIFICATE OF EXEMPTION
FOR SALES AND USE TAX ONLY
WELD COUNTY
915 1OTH ST
GREELEY CO 6O632-1117
ACCOUNT NUMBER
LIABILITY INFORMATION
ISSUE DATE
98-O3551
O3 O57 5999 9 O1O181
OCT 14 1988
915 1OTH ST GREELEY CO
Form _W-9
(Rev Never -lb'', 20051
o•Pi Nnen. p',miry
Inic'-a' ar enur -P
Request for Taxpayer
Identification Number and Certification
Give form to the
requester. Do not
send to the IRS.
ry Name las shown or your income tar relum)
C
0
Iv
Cr Rus,ress name 4 giHerent from above
C
c
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rid
o
2.
cc
[_ e
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6;
u Gly, stale. and ZIP code
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account numbers) here IOPlippaij
traiLl
n individual/
Check apvropr ate be. `—r Sole proprietor
Aooress (number, street, ano apt. Or suite nor
❑ Corporation 5 Partnersmp
VD
y
Taxpayer Identification Number (TIN'
Enter your TIN in the appropriate box. The TIN provided must match the name given o Line 1 to afetl
backup withholding. For individuals, this is your social security number (SSN). However. fora resident
alien, 501e proprietor, or disregarded entity, see the Part I instructions on page 3. For other t Is
your employer identification number (EIN). If you do not have a number, see How to gel a TIN,dn age 3.
Note. If the account is in more than one name, see the chart on page 4 for guidelines on wh0s9/
number to enter.
Part tl
Certification
!Employer identification number
14'11111
❑ Outer • I ❑ Exempt ird
wilhnoldmf
backup
IRequester's name ano acoress:,loptionail J (/
1 ^ I V :,>,
I
f
social secuffy number
I i' rI ill 11
or
i
Under penal! es co per;ury. I certify that:
1 The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withhold:no because: la) lam exempt from backup withholding, or ID) I have not been notified by the Internal
Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has
notified me that I am no longer subject to backup withholding, and
3. I am a U.S person (including a U.S. resident alien).
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have faded to report all interest and dividends on your lax return For real estate transactions, rlem 2 does not apply.
For mortgage interest paid, acquisition or abandonment of secured property. cancellation of debt, contributions to an individual retirement
arranoement (IRA), and generally, payments other than interest and dividends. you are not required to sign the Certification, but you must
provide your correct TIN. (See the instructions on page 4 i
Sign signature of
Here us. person ►
Date ►
Purpose of Form
A person who is required to file an information return with the
IRS. must obtain your correct taxpayer identification number
(TIN) to report, for example. income paid to you. real estate
transactions. mortgage interest you paid, acquisition or
abandonment of secured properly, cancellation of debt, or
contributions you made to an IRA.
U.S. person. Use Form W-9 only if you are a U.S. person
(including a resident alien), to provide your correct TIN to the
person requesting it (the requester) and, when applicable, to:
1. Certify that the TIN you are giving is correct (or you are
waiting for a number to be issued),
2. Certify that you are not subject to backup withholding, or
3. C'aim exemption from backup withholding if you are a
U.S. exempt payee.
In 3 above. if applicable, you are also certifying that as a
U.S. person, your allocable share of any partnership income
from a U S !rage or business is not subject to the
withholding tax on foreign partners' share of effectively
connected income.
Note. If a requester gives you a form other than Form W-9 to
'equest your TIN, you must use the requester's form if it is
substantially similar to this Form W-9.
For federal tax purposes, you are considered a person if you
• An individual who is a citizen or resident of the United
States,
• A partnership, corporation, company, or association
created or organized in the United States or under the laws
of the United Stales, or
• Any estate (other than a foreign estate) or trust. See
Regulations sections 301.7701-6(a) and 7(a) for additional
information.
Special rules for partnerships. Partnerships that conduct a
trade or business in the United States are generally required
to pay a withholding tax on any foreign partners' share of
income from such business. Further, in certain cases where a
Form W-9 has not been received, a partnership is required to
presume that a partner is a foreign person, and pay the
withholding tax. Therefore. if you are a U.S. person that is a
partner in a partnership conducting a trade or business in the
United States, provide Form W-9 to the partnership to
establish your U.S. status and avoid withholding on your
share of partnership income.
The person who gives Form W-9 to the partnership for
purposes of establishing its U S status and avoiding
withholding on its allocabie share of net income from the
partnership conducting a trade or business in the United
States is in the following cases.
• The U.S. owner of a dis•egarded entity and not the entity,
Cat. No 1C23 -x Form W-9 (Rev II 20051
For" W_9'Rea /2]051 Page Z
• The U.S. grantor or other owner of a grantor trust and not
the trust, and
• The U.S. trust (other than a grantor trust) and not the
beneficiaries of the trust.
Foreign person. If you are a foreign person, do not use
Form W-9. Instead, use the appropriate Form W-8 (see
Publication 515, Withholding of Tax on Nonresident Aliens
and Foreign Entities).
Nonresident alien who becomes a resident alien.
Generally, only a nonresident alien individual may use the
terms of a tax treaty to reduce or eliminate U.S. tax on
certain types of income. However, most tax treaties contain a
provision known as a 'saving clause." Exceptions specified
in the saving clause may permit an exemption from tax to
continue for „ .n a
type of income even Otter the roc .,t
has otherwise become a U.S. resident alien for tax purposes.
If you are a U.S. resident alien who is relying on an
exception contained in me saving clause of a tax treaty to
claim an exemption from U.S. tax on certain types of income,
you must attach a statement to Form W-9 that specifies the
following five items:
1. The treaty country. Generally, this must be the same
treaty under which you claimed exemption from tax as a
nonresident alien.
2. The treaty article addressing the income.
3 The article number (or location) in the tax treaty that
contains the saving clause and its exceptions.
4. The type and amount of income that qualifies for the
exemption from tax.
5. Sufficient facts to justify the exemption from tax under
the terms of the treaty article.
Example. Article 20 of the U.S.-China income tax treaty
allows an exemption from tax for scholarship income
received by a Chinese student temporarily present in the
United States. Under U.S. law, this student will become a
resident alien for tax purposes if his or her stay in the United
States exceeds 5 calendar years. However, paragraph 2 of
the first Protocol to the U.S.-China treaty (dated April 30,
1984) allows the provisions of Article 20 to continue to apply
even after the Chinese student becomes a resioent alien of
the United States. A Chinese student who qualifies for this
exception (under paragraph 2 of the first protocol) and is
relying on this exception to claim an exemption from tax on
his or her scholarship or fellowship income would attach to
Form W-9 a statement that includes the in'ormation
described above to support that exemption.
It you are a nonresident alien or a foreign entity not subject
to backup withholding, give the requester the appropriate
completed Form W-8.
What is backup withholding? Persons making certain
cayments to you must under certain conditions withhold and
day to the IRS 28% of such payments (after December 31,
?002). This is called "backup withholo:ng." Payments that
nay be subject to backup withholding include interest.
l ividenCs, broker and baler exchange transactions, rents,
oyalties, nonemployee pay, and certain payments from
siting boat operators. Real estate transactions are not
object to backup withholding.
You will not be subject to backup withholding on oayments
ou receive it you give the requester your correct TIN. make
to proper certifications, and report all your taxable interest
nd dividends on your tax return.
ayments you receive will be subject to backup
ithholding if:
1 You do not furnish your TIN to the requester.
2 You Co not certify your TIN when required (see the Part
instructions on page 4 for details).
3 The IRS tells the requester that you furnished an
incorrect TIN.
4. The IRS tells you that you are subject to backup
withholding because you did not report all your interest and
dividends on your tax return (for reportable interest and
dividends only), or
5. You do not certify to the requester that you are not
subject to backup withholding under 4 above (for reportable
interest and dividend accounts opened after 1983 only).
Certain payees and payments are exempt from backup
withholding. See the instructions below and the separate
Instructions for the Requester of Form W-9.
Also see Special rules regarding partnerships on page 1.
Penalties
Failure to furnish TIN. If you fail to furnish your correct TIN
to a requester, you are subject to a penalty of $50 for each
such failure unless your failure is due to reasonable cause
and not to willful neglect.
Civil penalty for false information with respect to
withholding. If you make a false statement with no
reasonable basis that results in no backup withholding, you
are subject to a $500 penalty.
Criminal penalty for falsifying information. Willfully
falsifying certifications or affirmations may subject you to
criminal penalties including fines and/or imprisonment.
Misuse of TINs. if the requester discloses or uses TINs in
violation of federal law, the requester may be subject to civil
and criminal penalties.
Specific Instructions
Name
If you are an individual, you must generally enter the name
shown or. your income tax return. However, if you have
changed your last name, for instance. due to marriage
without informing the Social Security Administration of the
name change. enter your first name, the last name shown on
your social security card, and your new last name.
If the account is in joint names, list first, and then circle,
then m ct the person or entity whose number you entered
in Part I of the form
Sole proprietor. Enter your individual name as shown on
your income tax return on the "Name" line You may enter
your business, trade. or "doing business as (CBA)" name on
the "Business name" line.
Limited liability company (LLC). If you are a single -member
LLC (including a foreign LLC with a domestic owner) that is
disregarded as an entity separate from its owner under
Treasury regulations section 3017701-3, enter the owner's
name on the "Name" line Enter the LLC's name on the
"Business name" line. Check the appropriate box for your
filing status (sole proprietor, corporation, etc ), then check
the box for "Other" and enter "LLC" n the space provided.
Other entities. Enter your business name as shown on
required federal tax documents on the "Name" line. This
name should match the name snown on the charter or other
legal document creating the entity. You may enter any
business, trade. or DBA name on the "Business name" line.
Note. You are requested to check the appropriate box for
your status (Individual/sole proprietor, corporation, etc.).
Exempt From Backup Withholding
If you are exempt, enter your name as described above and
check the appropriate box for your status, then check the
Exempt from backup withholding" box in the line following
the business name, sign and Cate the form.
fort- in 9 tnry •I -Pecs) rage 3
• Generally. Individuals (including sole proprietors) are not
exempt from backup withholding. Corporations are exempt
from backup withholding for certain payments, such as
interest and dividends.
Note. If you are exempt from backup withholding, you
should still complete this form 10 avoid possible erroneous
backup withholding.
Exempt payees. Backup withholding is not required on any
payments made to the following payees:
1. An organization exempt from tax under section 501(a),
any IRA. or a custodial account under section 403(b)(7) if the
account satisfies the requirements of section 401(f)(2),
2. The United States or any of its agencies or
instrumentalities,
United States, or any of their political subdivisions or
instrumentalities,
4. A (ureiyii yuverruuent ur any of iia puiilicai subdivisions,
agencies, or instrumentalities, or
5. An international organization or any of its agencies or
instrumentalities.
Other payees that may be exempt from backup
withholding include:
6. A corporation,
7. A foreign central bank of issue,
8. A dealer in securities or commodities required to register
in the United States, the District of Columbia, or a
possession of the United States,
9. A futures commission merchant registered with the
Commodity Futures Trading Commission,
10. A real estate investment trust,
11. An entity registered at all times during the tax year
under the Investment Company Act of 1940,
12. A common trust fund operated by a bank under
section 584(a),
13. A financial institution,
14. A middleman known in the investment community as a
nominee or custodian, or
15. A trust exempt from tax under section 664 or
described in section 4947.
The chart below shows types of payments that may be
exempt from backup withholding. The chart applies to the
exempt recipients listed above, 1 through 15.
IF the payment is for ...
THEN the payment is exempt
for..
Interest and dividend payments
All exempt recipients except
for 9
Broker transactions
Exempt recipients 1 through 13.
Alsoa person registered under
the Investment Advisers Act of
1980 who regularly acts as a
broker
ia'Ier exchange transactions
and patronage dividends
Exempt recipients 1 through 5
'ayments over £6C0 required
be reported and direct
ales over £5.300'
Gereraly, exempt recipients
1 through 7
See Form ;099'IVISC. M sceraneous :ncor-'e. arc its :nstrvct'ors
l owe•er re Iciiowin0 oapoems rdde ''o a corporatior i'ndoo'rs 0,055
>roc eecs 030 to an attorney c-ae' sect a- 6C<5:r. ever d the a:to•ney is a
:0,00'510'D a -C reporlaa a on Form 1099 MISC are rot exempt fron'
,a0k uc v'P^od'no meOca arc hex:lrr care pa:n'_ents allorreys tees and
iaymenls for servi:e5 pai0 by a lecera' caecur, a a5ercy
Part I. Taxpayer Identification
Number (TIN)
Enter your TIN in the appropriate box. If you are a resident
alien and you do not have and are not eligible to get an SSN,
your TIN is your IRS individual taxpayer identification number
(ITIN). Enter it in the social security number box. If you do
not have an ITIN, see How to get a TIN below.
If you are a sole proprietor and you have an EIN, you may
enter either your SSN or EIN. However, the IRS prefers that
you use your SSN.
If you are a single -owner LLC that is disregarded as an
entity separate from its owner (see Limited liability company
(LLC) on page 2), enter your SSN (or EIN, if you have one). If
the LLC is a corporation, partnership, etc., enter the entity's
clIV.
Note. See the chart on page 4 for further clarification of
name and TIN combinations.
How to get a TIN. If you do not have a TIN, apply for one
immediately. To apply for an SSN, get Form SS -5,
Application for a Social Security Card, from your local Social
Security Administration office or get this form online at
www.socialsecurity.gov. You may also get this form by
calling 1-800-772-1213. Use Form W-7, Application for IRS
Individual Taxpayer Identification Number, to apply for an
lilts!, or Form SS -4, Application for Employer Identification
Number, to apply for an EIN. You can apply for an EIN online
by accessing the IRS wens.^.e at www.irsgov!buslnesses and
clicking on Employer ID Numbers under Related Topics. You
can get Forms W-7 and SS -4 from the IRS by visiting
www.irs.gov or by calling 1 -800 -TAX -FORM
(1-800-829-3676).
It you are asked to complete Form W-9 but do not have a
TIN, write 'Applied Fur" in the space for the TIN, sign and
date the form. and give it to the requester. For interest and
dividend payments, and certain payments made with respect
to readily tradable instruments, generally you will have 60
days to get a TIN and give it to the requester before you are
subject to backup withholding on payments. The 60 -day rule
does not apply to other types of payments. You will be
subject to backup withholding or all such payments until you
provide your TIN to the requester.
Note. Writing "Applied For" means that you have already
applied for a TIN or that you intend to apply for one soon.
Caution: A disregarded domestic entity that has a foreign
owner must use the appropriate Form W-8.
nage 9
Part II. Certification
To establish to the withholding agent that you we a U.S.
person. or resident alien, sign Form W-9. You may be
requested to sign by the withholding agent even if items 1, 4,
and 5 below indicate otherwise.
For a joint account, only the person whose TIN is shown in
Part I should sign (when required). Exempt recipients, see
Exempt From Backup Withholding on page 2.
Signature requirements. Complete the certification as
indicated in 1 through 5 below.
1. Interest, dividend, and barter exchange accounts
opened before 1984 and broker accounts considered
active during 1983. You must give your correct TIN, but you
do not have to soon the certification.
2. Interest, dividend, broker, and barter exchange
accounts opened after 1983 and broker accounts
considered inactive during 1963. You mutt Svgn the
certification or backup withholding will apply. If you we
subject to backup withholding and you are merely providing
your correct TIN to the requester, you must cross out item 2
in the certification before signing the form.
3. Real estate transactions. You must sign the
certification. You may cross out item 2 of the certification.
4. Other payments. You must give your correct TIN, but
you do not have to sign the certification unless you have
been notified that you have previnusly given an incorrect TIN.
"Other payments" include payments made in the course of
the requester's trade or business for rents. royalties. goods
(other than bills for merchandise). medical and health care
services (including payments to corporations), payments to a
nonemployee for services, payments to certain fishing boat
crew members and fishermen, and gross proceeds paid to
attorneys (including payments to corporations).
5. Mortgage interest paid by you, acquisition or
abandonment of secured property, cancellation of debt,
qualified tuition program payments (under section 529),
IRA, Coverdell ESA, Archer MSA or HSA contributions or
distributions, and pension distributions. You must give
your correct TIN, but you do not have to sign the
certification.
What Name and Number To Give the
Requester
For this type of account. l Give name and SSN or
1 Individual j The individual
2. Two or more individuals (Joint The actual owner of the account
account) or, if combined funds. the first
individual on the account '
3. Custodian account of a minor The minor'
(Uniform Gift tc Minors Act)
4. a. The usual revocable
savings trust (grantor is
also trustee)
b. So-called trust account
that is no! a legal or valid
trust under stale law
5. Sole proprietorship or
;angle -owner LLC
For this type of account
The grantor -trustee '
The actual owner '
The owner 3
Give name and SIN of:
Tee owner 3
Legal entity
The corporation
6. Sole proprietorship or
single -owner LLC
7. A valid trust, estate, or
pension trust
8. Corporate or LLC electing
corporate status on Form
8832
9. Association, club, religious,
charitable, educational, or
other tax-exempt organization
10. Partnership or multi -member
LLC
11. A broker or registered
nominee
12 Account with the Department
of Agriculture in the name of
a public entity (such as a
state or local government,
school district, or prison) that
receives agricultural program
payments
The organization
The partnership
The broker or nominee
The public entity
L.st first ar o circle the name of the person whose number you turn'sn II
only one person on a Joint account has an SSN. that person's number must
be furnished.
c lute the rn'nois name and furnish the minors SSN
Lot, must show your indviduaname and you may a!s0 enter your business
or 'OBA' name on the secone name Lne. you may use either your SSN or
FN Id you have one) if you are a sole proprietor. IRS encourages you to
use your SSN
LSI Ivst and circle the name of the legal trustestate, or pension trust loo
not furr-sh the TIN of the persona' fepresenlar ire or trustee unless toe legal
enkty rise t s not des rated in inc account the I Aso see Special rules
regarding parnerships or oage t.
Note. If no name is circled when more than one name is
listed, the number will be considered to be that of the first
name listed.
'rivacy Act Notice
action 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns
th the IRS to report interest d'v,ce❑es. and certain other income paid to you, mortgage interest you paid, the acquisition or
bandonment of secured property. cancellation of debtor contributions you made to an IRA, or Archer MSA or HSA. The IRS
ses the numbers for identification purposes and to help verify the accuracy of your tax return. The IRS may also provide this
formation to the Department of Justice for civil and criminal litigation, and to cities, states. the District of Columbia, and U.S.
ossessions to carry out their lax laws. We may 050 disclose this -formation to other countries under a tax treaty, to federal
'd state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to comtat
rrorism
You must provide your TIN whether or rot you are rec.hred to foie a tax return Payers must generally withhold 28% of taxable
'erest, diva:enc. and certain other cayments to a payee v✓no ages not give a TIN to a payer. Certain penalties ma) also apply.
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.
//-3 -0
DATE
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