HomeMy WebLinkAbout20092815.tiffNADOA Model Form Division Order (Adopted 9/95
DIVISION ORDER
FOUNDATION ENERGY
1900 GRANT STREET, SUITE 1120
DENVER, COLORADO 80203
Property Number: 2023
Property Name: BARNEY 8
Operator: FOUNDATION ENERGY
County and State: WELD, COLORADO
Production:
Date: 10/01/09
Effective Date: First Settlement
Oil X GasX Other
Owner Name WELD COUNTY OWNER NUMBER: 3071
And Address: A POLITICAL SUBDIVISION OF THE STATE OF COLORADO Type of Interest: R
915 10th STREET, 3RD FLOOR Decimal Interest: 0.00006953
GREELEY, CO 80631
The undersigned certifies the ownership of their decimal interest in production or proceeds as described above payable by Foundation
Energy (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 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 amounts equal $100.00 or until December 315' of each year, whichever occurs first, as
required by applicable state statue.
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) :
Owner(s) Signature (s) :
Owner(s)Tax I. D. Number(s):
William F. Garcia, Chair
10/26/2009
84-6000-813
Owner Daytime Telephone #: 970-356-4000 X4200
Owner FAX Telephone #:
970-352-0242
Attest:
By:
Cl
Deputy Cl
r
Federal Law requires you to furnish your Social Security or Taxpayer Identification Number.
Failure to comply will result in 28% withholding tax and will not be refundable by Payor.
Co-iO%a aaoo�
ea, , FOLk.P.I.D otil Cl t)
690.09-alis
L cmo=y
/6/3o/oi
.1
WELD COUNTY
COf- MQ1Oi''+ERS
J FOUND ON aci -2 A 10: 22
oaq
FOUNDATION ENERGY MANAGEMENT, LLCt
1900 GRANT STREET, SUITE m12"0- t`' 1 y r
DENVER, CO 80201
Division Order Department
October 1, 2009
Barney 8 Well
Weld County, Colorado
Dear Interest Owner:
Please read the following instructions before signing the enclosed Division Orders.
These instruments should not be altered in any way unless accompanied by documentary evidence to support the
change. Do not eliminate any of the covenants and/or clauses shown thereon.
If you name and interest are correctly shown:
SIGNATURE:
Sign name as shown on instrument, and have your signature witnessed, (Two witnesses are required in Louisiana and in
Mississippi but only one elsewhere). If signing for a corporation, signature must be attested, corporate seal affixed, and title
of the signatory party shown. Any firm or partnership must have signatures of all partners.
SIGNATURE BY SECOND PARTY:
If the Division Orders are signed by any party other than the named interest owner, we must have evidence of the rights
vested in the signatory party.
SOCIAL SECURITY NUMBER OR TAX NUMBER:
Insert your number in the space provided on the Division Orders.
By Law, we are required to withhold 28% of proceeds for those payees that fail to furnish us Social Security or Taxpayer
identification Numbers, effective January 1, 1984.
CURRENT MAILING ADDRESS:
Print or type the address to which checks are to be mailed.
NOTIFICATION OF ADDRESS CHANGE:
This notification in writing of any change in your mailing address must be over your own signature or that of your
appointed agent. It must include your owner number, your old address, and your new address with zip code.
SETTLEMENT FOR YOUR INTEREST:
Upon receipt of the properly executed instrument and evidence of clear title, the interest credited to you will be authorized
for payment. Checks will be mailed monthly when accruals to your interest equal $100.00 or more.
LEASE NUMBER:
This is in the upper left corner of the Division Orders and also appears on your check statements. Please use this number
when corresponding.
Please return one fully executed counterpart of the Division Orders to the letterhead address, keeping one copy for
your records.
If you have any questions please call Debbie Green at (303) 861-0504 ext. 201 or David Richardson at ext. 202.
Q FOUNDATION
I' ENERGY COMPANY
Foundation Energy Management, LLC
1900 Grant Street #1120
Denver, Colorado 80203
October 1, 2009
Weld County
A political subdivision of the State of CO.
915 10th Street, 3rd Floor
Greeley, CO 80631
Re: Division Order
Barney 8 Well
Township 6 North, Range 66 West, 6th PM
Section 23: SESW
Weld County, Colorado
Dear Owner:
Foundation Energy Management, LLC recently drilled and completed the referenced well. Our
title work indicates that you are entitled to the Royalty Interest as indicated on the enclosed
division order.
Please take a moment to read through the enclosed instruction page and division order. If
everything appears correct please return a completed original to the Denver, Colorado address
listed on top of the division order form. The form marked COPY is for your records.
If you have any questions please do not hesitate to call me at (303) 861-0504 ext 201.
Sincerely,
Foundation Energy Management, LLC
Debbie K. Green
Land Administrator
Enclosures
Tulsa Office
601 S. Boulder Ave., Suite 600
Tulsa, Oklahoma 74119
P: 918-585-1650 F: 918-585-1660
Corporate Office
14800 landmark Blvd Suite 220
Dallas, Texas 75254
P: 972-934-83S5 F: 972-934-8610
Denver Office
1900 Giant Street, Suite 1120
Denver, Colorado 80203
P: 303-861-0504 F: 303-861-0604
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: - L. --
/956t- oun Attorney DATE: g /9 c
Hello