HomeMy WebLinkAbout20080656.tiff •
RECEIVED
9r1
0CT E 2012 NADOA Model Form Division Order(Mooted 9/951
e, noble DIVISION ORDER
energy WELD COUNTY
COMMISSIONERS
Return To: NOBLE ENERGY,INC Desk Code: YHU 123378
1625 BROADWAY STE 2200 Date: OCT 12 2012
DENVER CO 80202 US Effective Date: JUL 2012
Property GRIGSYOperatorName: NOBLEBENPINCNI Apt C6- 123- 34855
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 435820848 124102-8 0.12500000 RI
%BOARD OF COUNTY COMMISSIONER
WELD COUNTY CENTENNIAL CENTER
P 0 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$25.00,or clear ALL payable proceeds in January 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: RETAIN FOR YOUR RECORDS
Owner(s)Signature(s): Sean P. Conway, Chair
Owner(s)Tax I.D.Number(s): 84-6000-813 OCT 2 2 2012
TIN(s)or SSN(s)
Owner Daytime Telephone/Fax#: 970-336-7204
Address Correction:
Federal Law requires you to furnish your Social Security or Taxpayer Identification Number.Failure to comply will result in tax withholding in accordance with
federal law,which will not be refundable by Payor.
2012-2972
i� 74
Le 0,1,1,3
NOBLE ENERGY,INC. Property Description Attachment
Property Name : GRIGSBY PC AC30-73HN NI
Operator : NOBLE ENERGY,INC
County/Parish and State : WELD, CO
Property Description
T7N R63W SEC 36: E2 CONTANING 320 ACRES MORE OR LESS,WELD COUNTY,CO
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
Bra?, pfry)
Controller
Colorado statute exempts from state and state-collected sales tax all sales to the United States government and the State of
Colorado,its departments and institutions,and its political subdivisions(county and local governments,school districts and special
districts)in their governmental capacities only.(C.R.S.39-26-114)1)(a)(I)).
Some governmental entities have a Colorado-issued tax-exemption number,although they am not required to have one. Following
is a copy of Weld County Government's most recent Colorado-issued Certificate of Exemption for Sales and Use Tax Only.
EJIR WO
AAZ2T OF REVENUE State of Colorado
,m swum rawer
COWER.COLORADO Q261
ThS WENSE IS NOT TRANSFERABLE CERTIFICATE OF EXEMPTION
FOR SALES AND USE TAX ONLY
WELD COUNTY
915 1OTH ST
GREELEY CO 80632-1117 ......_. f`,
LIABU Y NFOarAATxN .
ACCOUNT NUMBER ISSUE DATE
98-O3551 O3 057 5999 9 010181 OCT 14 1988
915 1OTH ST GREELEY CO Encodscuctot
Daparomitas Rennin
sre
0
For, We9 Request for Taxpayer Give form to the
Rev.November
T°e', identification Number and Certification requester.Do not
swimenray»*'mw send to the IRS.
wend Penn,.Service
of Name(as shown on sow Yxome tax relum)
d Business name,A different from above
o`
„ ❑ skt pr ❑ CorporationPartnership Exempt from backup
b Check aplxoprlsla box: Sole proprietor O ❑ Other► withholding
«e Address plumber,street and apt,or suite no.) Repwatw's name and address(optional
> Pty.state.and ZIP code
N List account gnumber(s)here(optional
Par I Taxpayer Identification Number(TIN)
Enter your TIN in the appropriate box.The TIN provided must match the name given on line Ito avoid Social aeauNy nwnber
backup withholding.For individuals„this is your social security number(SSN).However,for a resident I 1 + I + I I I
aken,sole proprietor,or disregarded entity,see the Part I instructions on page 3.For other entities,it is
your employer identification number(EIh).If you do not have a number,see Flow to get a TIN on page 3. or
Note.If the account is in more than one name,see the chart on page 4 for guldernn on whose Employer denmcatbn number
number to
enter. I + I I I I I 1
Part II Certification
Under penalties of perjury.I certify that:
1. The number shown on this form is my correct taxpayer identification number Cori am waiting for a number to be issued to me),and
2. I am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)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 em no longer subject to backup withholding,and
3. I am a U.S.person(including a U.S.resident alien).
CeaafcatIon lnabuetlons.You must cross out item 2 above if you have been notified by the IRS that you am currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.
For mortgage interest paid,acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement
arrangement(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.)
Sign •kdnewe•t
Hare lit person► oats►
Purpose of Form • An individual who is a citizen or resident of the United
A person who is required to file an information return with the States,
IRS,must obtain your correct taxpayer identification number • A partnership,corporation,company,or association
(TIN)to report for example,income paid to you,real estate created or organized in the United States or under the laws
transactions,mortgage Interest you paid,acquisition or of the United States,or
abandonment of secured property,cancellation of debt,or •Any estate(other than a foreign estate)or trust.See
contributions you made to an IRA. Regulations sections 301.7701-6(a)and 7(a)for additional
U.S.parson.Use Form W-9 only if you are a U.S.person information.
(including a resident alien),to provide your correct TIN to the Special See for partnerships.Partnerships that conduct a
person requesting it(the requester)and,when applicable,to: trade or business in the United States are generally required
1.Certify that the TIN you are giving is correct(or you are to pay a withholding tax on any foreign partners'share of
waiting for a number to be issued). income from such business.Further,in certain cases where a
2.Certify that you are not subject to backup withholding,or Form W-9 has not been received,a partnership is required to
3.Claim exemption from backup withholding If you are a presume that a partner is a foreign person,and pay the
withholding tax.Therefore,if you are a U.S. person that is a
U.S.exempt payee.
In 3 above,if applicable,you are also certifying that as a partner In a partnership conducting a trade or business in the
United States,provide Form W-9 to the partnership to
U.S.person,your allocable share of any partnership income establish your U.S.status and avoid withholding on your
from a U.S.trade or business Is not subject to the share of partnership income.
withholding tax on foreign partners'share of effectively
connected Income. The person who gives Form W-9 to the partnership for
Note.If a requester gives you a form other than Form W-9 to purposes of establishing its U.S.status and avoiding
request your TIN,you must use the requester's form If it is withholdingip on its allocabletrade share of s n ss A,income from the
substantially similar to this Form W-9. Sartesrshin conducting a or business in the United
ses:
For federal taxStates me Is in.the owner forof and Cegar
are: purposes,you are considered a person if you •The U.S. of a disregarded entity and not the entity,
Cal.Ile.10231% Form W-9 (Rev.11.20os)
ew
Form W-9 Rev.11-20051 Page 2
•The U.S.grantor or other owner of a grantor trust and not 3.The IRS tells the requester that you furnished an
the trust,and incorrect TIN.
•The U.S.trust(other than a grantor trust)and not the 4.The IRS tells you that you are subject to backup
beneficiaries of the trust. withholding because you did not report all your interest and
Foreign parson.If you area foreign person,do not use dividends on your tax return(for reportable interest and
Form W-9.Instead,use the appropriate Form W-8(see dividends only),or
Publication 515,Withholding of Tax on Nonresident Aliens 5.You do not certify to the requester that you are not
and Foreign Entitles)- subject to backup withholding under 4 above(for reportable
Nonresident also who becomes a resident alien. Interest and dividend accountsopened after 1983 only).
Generally,only a nonresident alien Individual may use the Certain payees and payments are exempt from backup
terms of a tax treaty to reduce or eliminate U.S.tax on withholding.See the instructions below and the separate
certain types of Income.However,most tax treaties contain a Instructions for the Requester of Form W-9.
provision known as a"saving clause."Exceptions specified Also see Special rules regarding partnerships on page 1.
In the saving clause may permit an exemption from tax to
continue for certain types o income even after the recipient Penalties
has otherwise become a U.S.resident alien for tax purposes. Failure to furnish TIN.If you fall to furnish your correct TIN
If you are a U.S.resident alien who is relying on an to a requester,you are subject to a penalty of 550 for each
exception contained in the saving clause of a tax treaty to such failure unless your failure is due to reasonable cause
claim an exemption from U.S.tax on certain types of Income, and not to willful neglect.
you must attach a statement to Form W-9 that specifies the CM penalty for false Information with respect to
following five items: withholding.If you make a false statement with no
1.The treaty country.Generally,this must be the same reasonable basis that results in no backup withholding,you
treaty under which you claimed exemption from tax as a are subject toe 8500 penalty.
nonresident alien. Criminal penalty for falsifying information.Willfully
2.The treaty article addressing the income. falsifying certifications or affirmations may subject you to
3.The article number(or location)in the tax treaty that criminal penalties including fines and/or imprisonment.
contains the saving clause and its exceptions. Misuse of TINS.If the requester discloses or uses TINs in
4.The type and amount of income that qualifies for the violation of federal law,the requester may be subject to civil
exemption from tax. and criminal penalties.
5.Sufficient facts to justify the exemption from tax under
the terms of the treaty article. Specific Instructions
Example.Article 20 of the U.S.-China income tax treaty Name
atoms an exemption from tax for scholarship income you at are an individual,received by a Chinese student temporarily present in theyou must generally enter the name
United States.Under U.S.law,this student will become a shown on your income tax return.However,if you have
resident alien for tax purposes if his or her stay in the United changed your last name,for instance,due to marriage
States exceeds 5 candy years.However,paragraph 2 of without informing the Social Security Administration of the
the first Protocol to the U.S.-China treaty(dated April 30, name change,enter your first name,the last name shown on
1984)allows the provisions of Article 20 to continue to apply your social security card,and your new last name.
even after the Chinese student becomes a resident alien of It the account is in joint names,list first,and then circle,
the United States.A Chinese student who qualifies for this the name of the person or entity whose number you entered
exception(under paragraph 2 of the first protocol)and is in Part I of the form.
relying on this exception to claim an exemption from tax on Sole proprietor.Enter your individual name as shown on
his or her scholarship or fellowship income would attach to your income tax return on the"Name"line.You may enter
Form W-9 a statement that includes the information your business,trade,or"doing business as(DBA)"name on
described above to support that exemption- the"Business name"line.
If you are a nonresident alien or a foreign entity not subject Limited liability company(LLC).If you are a single-member
to backup withholding,give the requester the appropriate LLC(including a foreign LLC with a domestic owner)that is
completed Form W-8. disregarded as an entity separate from its owner under
What Is backup withholding?Persons making certain Treasury regulations section 301.7701-3,enter the owner's
payments to you must under certain conditions withhold and name on the"Name"line.Enter the LLC's name on the
pay to the IRS 28%of such payments(after December 31, "Business name"line.Check the appropriate box for your
2002).This is called"backup withholding."Payments that filing status(sole proprietor,corporation,etc.),then check
may be subject to backup withholding include interest, the box for"Other"and enter"LLC"in the space provided.
dividends,broker and barter exchange transactions,rents, Other entities.Enter your business name as shown on
royalties,nonemployee pay,and certain payments from required federal tax documents on the"Name"line.This
fishing boat operators.Real estate transactions are not name should match the name shown on the charter or other
subject to backup withholding. legal document cresting the entity.You may enter any
You will not be subject to backup withholding on payments business,trade,or DBA name on the"Business name"line.
you receive if you give the requester your correct TIN,make Note.You are requested to check the appropriate box for
the proper certifications,and report all your taxable interest your status(individual/sole proprietor,corporation,etc.).
and dividends on your tax return.
Payments gy u receive will be subject to backup Exempt From Backup Withholding
wesseais1.You do not furnish your TIN to the requester,it check you�esempt,enter box for o name or as described check thabove e
equappropriate your status,then the
2.You do not certify your TIN when required(see the Part "Exempt from backup withholding"box In the line foilowng
II Instructions on page 4 for details), Me business name,sign and date the form.
Form w-9(Rev.11-2005)
Pepe 3
Generally,individuals Including sole proprietors)are not Part I. Taxpayer Identification
exempt from backup withholding.Corporations are exempt
from backup withholding for certain payments,such as Number (TIN)
interest and dividends. Enter your TIN In the appropriate box.Ifyou are a resident
Note.If you are exempt from backup withholding,you alien and you do not have and are not eligible to get an SSN,
should still complete this form to avoid possible erroneous your TIN is your IRS individual taxpayer identification number
backup withholding. (DIN).Enter 8 in the social security number box.If you do
Exempt payees.Backup withholding la not re not have an RIN,see How to get a TIN below.
payments made to the following payees: axed on any If you are a sole proprietor and you have an EIN,you may
1.An organization exempt from tax under section 501(a), enter either your SSN or EIN.However,the IRS prefers that
you use your SSN.
any IRA,or a custodial account under section 403(b)(7)if the
account satisfies the requirements of section 401()(2), If you are a single-owner LLC that is disregarded as an
2.The United States or any of its agencies or entity separate from its owner(see Limited habiliy company
instrumentalities, (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
3.A state,the District of Columbia,a possession of the EIN.
United States,or any of their political subdivisions or Note.See the chart on ge 4 for further clarification of
instrumentalities, name and TIN conbinati�orhs.
4.A foreign government or any of its political subdivisions,
agencies,or instrumentalities,or How to get a TIN.If you do not have a TIN,apply for one
immediately.To apply(or an SSN.get Form SS-5,
5.An International organization or any of its agencies or
Application for a Social Security Card,from your local Socialinstrumentalities.
Other payees that may be exempt from backup Security Administration office or get this form online at
P www.sxWlsecuritygov.You may also get this form by
withholding include: calling 1-800-772-1213.Use Form W-7,Application for IRS
6.A corporation, Individual Taxpayer Identification Number,to apply for an
7.A foreign central bank of Issue, (TIN,or Form SS-4,Application for Employer Identification
8.A dealer in securities or commodities required to register Number,to apply for an ON.You can apply for an EIN onine
in the United States,the District of Columbia,of a by accessing the IRS website at www.ir3.gov/businesses and
possession of the United States, clicking on Employer ID Numbers under Related Topics.You
9.A futures commission merchant registered with the can get Forms W-7 and SS-4 from the IRS by visiting
Commodity Futures Trading Commission, www.rrs.gov o by calling 1.800-TAX-FORM
(1-800-829-3676).
10.A real estate investment trust, If you are asked to complete Form W-9 but do not have a
11.An entity registered at all times during the tax year TIN,write"Applied For"in the space for the TIN,sign and
under the Investment Company Act of 1940. date the form,and give It to the requester.For interest and
12.A common trust fund operated by a bank under dividend payments,and certain payments made with respect
section 584(a), to readily tradable Instruments,generally you will have 60
13.A financial institution, days to get a TIN and give it to the requester before you are
subject to backup withholding on payments.The 80-day rule
14.A middleman known in the Investment community as a does not apply to other types of payments.You will be
nominee or custodian,or subject to backup withholding on all such payments until you
15.A trust exempt from tax under section 664 or provide your TIN to the requester.
described in section 4947. Note.Writing"Applied For"means-hat you have already
The chart below shows types of payments that may be applied for a TIN or that you intend to apply for one soon.
exempt from backup withholding.The chart applies to the Caution:A disregarded domestic entity that has a foreign
exempt recipients listed above, 1 through 15. owner must use the appropriate Form W-8.
IF the payment Is for... THEN the peyrtwut I.exempt
fur...
Interest and dividend payments All exempt recipients except
for 9
Broker transactions Exempt recipients 1 through 13.
Also,a person registered under
the Investment Advisers Act of
1940 who regularly acts as a
broker
Barter exchange transactions Exempt recipients 1 through 5
and patronage dividends
Payments over 5600 required Generally,exempt recipients
to be reported and direct 1 through 7'
sales over$5,000'
'See Form 1099-MISC,MimUleneeua Income,and its instructions.
'However,the loosing payments made to a corporation(including arose
proceeds paid to an attorney under section(045p),even 4 the attorney is a
corporation)and reportable on Form 1099-MISC are not exempt from
backup widfotng:Medical and health care payments,attorneyi lees;and
payments for senk:es paid by a federal executive agency,
Form W-9(tar.11-2005) Page 4
Part II. Certification What Name and Number To Give the
To establish to the withholding agent that you are a U.S. Requester
person,or resident alien,sign Form W-9.You may be
requested to sign by the withholding agent even if items 1,4, For this type of account site name and UN at
and 5 below Indicate otherwise. I.Individual The individual
For a Joint account,only the person whose TIN is shown in 2.Two or more individuals(joint The actual owner of the account
Part I should sign(when required).Exempt recipients,see account) or,if combined funds,the first
Exempt From Backup Withholding on page 2. Individual on the account'
Signature requirements.Complete the certification as 3.Custodian account of a minor The minor a
indicated in 1 through 5 below. (Uniform Gift to Minors Act)
1 Interest,dividend,and barter exchange 4.a.The usual revocable The grantor-trustee'
accounts savings trust(grantor is
opened before 1984 and broker accounts considered also trustee)
active during 1983.You must give your correct TIN,but you b.So-called trust account The actual owner'
do not have to sign the certification. that is not a legal or valid
2.Interest,dividend,broker,and barter exchange trust under state law
accounts opened after 1983 end broker accounts 5.Sole proprietorship or The owner a
considered Inactive during 1983.You must sign the single-owner LLC
certification or backup withholding will apply.I1 you we For fhb type of account: oba name and alb at
subject to backup wsth holoing and you we merely providing
your correct 11N to the requester,you must cross out item 2 6.Sole proprietorship or The owner'
in the certification before signing the form. Single-owner LLC
7.A valid trust,estate,or Legal entity'
3.Real estate transactions.You must sign the pension trust
certification.You may cross out item 2 of the certification. e.Corporate or LLC electing The corporation
4.Other payments.You must give your correct TIN,but corporate status on Form
you do not have to sign the certification unless you have 8832
been notified that you have previously given an incorrect TIN. 9.Association,club,religious, The organization
"Other payments"include payments made in the course of charitable,educational,or
the requester's trade or business for rents,royalties,goods other tax-exempt organization
(other than bills for merchandise),medical and health care 10.Partnership or multi-member The partnership
services(including payments to corporations),payments to a LLC
nonemployee for services,payments to certain fishing boat 11.A broker or registered The broker or nominee
crew members and fishermen,and gross proceeds paid to nominee
attorneys(including payments to corporations). 12.Account with the Department The public entity
5.Mortgage Interest paid by you,acquisition or of Agriculture bicentity
in the name of
abandonment of secured property,cancellation of debt, a public or lcay(such as t
qualified tuition program payments(under section 629), state or district,ls government,
school sagricultural
or prison)lrothat
IRA,CoveNefi ESA,Archer MSA or HSA contributions or receives agricultural program
distributions,and pension distributions.You must give payments
your correct TIN,but you do not have to sign the
certification. 'list prat and circle the name of the parson ribose cumber you furnish.It
only one person on a joint account has en SSN,that person's number must
be furnished.
'Circle the mina's name and furnish the minor's SSN.
'You must show your Individual none and you may abo enter your business
or'DOA"name on the second name line.You may use either your SSN or
EN(e you have anti).II you are a sole proprietor.IRS encourages you to
use your SSN.
`list feat and circle the name of the legal trust estate.or pension trust.(Do
not furnish the TIN of the personal representative or trustee unless the legal
entity itself is not designated in the account hid.)Also see Special rubs
regarding pee nasnps on page I.
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.
Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns
with the IRS to report interest,dividends,and certain other income paid to you,mortgage interest you paid,the acquisition or
abandonment of secured property,cancellation of debt,or contributions you made to an IRA,or Archer MSA or NSA.The IRS
uses the numbers for Identification purposes and to help verify the accuracy of your tax return.The IRS may also provide this
information to the Department of Justice for civil and criminal litigation,and to cities,states,the District of Columbia,and U.S.
possessions to carry out their tax laws.We may also disclose this information to other countries under a tax treaty, to federal
and state agencies to enforce federal nontax criminal laws,or to federal law enforcement and intelligence agencies to combat
terrorism.
You must provide your TIN whether or not you are required to file a tax return.Payers must generally withhold 28%of taxable
Interest,dividend,and certain other payments to a payee who does not give a TIN to a payer.Certain penalties may also apply.
PETRO-CANADA• Petro-Canada Resources (USA) Inc.
WELD COUNTY
FEB -8 A II: 01
•
•
February 7, 2008
TO: Interest Owners
Re: NEW WELL DIVISION ORDER(S)
Weld County, CO
Ladies and Gentlemen:
Petro-Canada Resources (USA) Inc. (as"OPERATOR") has drilled and completed the well or wells as
referenced in the enclosed Division Order(s) in which you own an interest. Therefore, 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.
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.
Sincerely,
PETR� RESOURCES INC.
Aubrie M. Smith
Jr. Division Order Analyst
Aubrie.Sm ith(a�petro-canada.com
/ams
Enclosure
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.
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 appli
BY:
Co Attorney
DATE: 9 c�d J n lJ
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