HomeMy WebLinkAbout20082926.tiff DIVISION ORDER
To: Petro-Canada Resources (USA) Inc. Date: October 6, 2008
� 999 18th Street, Suite 600 Effective Date: First Production
, Denver, CO 80202-1904
RETAIN THIS COPY FOR
*Well Name: Perkins 29-45 YOUR FILE
Property Number: 13534
Prospect: Weld County Leasing Program (DO NOT DETACH EXHIBIT "A")
Operator: Petro-Canada Resources (USA) Inc.
County and State: Weld County, Colorado
Property Description: T4N, R68W, 6th P.M., Section 29: SE/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 $25.00, or pay once a year whichever occurs first,
or as required by applicable state statute.
This Division Order does not amend any lease or operating agreement between the undersigned and the
lessee or operator or any other contracts for the purchase of oil or gas.
In addition to the terms and conditions of this Division Order, the undersigned and Payor may have ce . ��
statutory rights under the laws of the state in which the property is located. .,‘-:\4
r', [, ;
Special Clauses: None
A A;
Owner(s) Signature: F A-t ATTEST:
William H. Jerke, Chair C •r to t . Bob"t truer'
Social Security/Tax ID Number(s) 84-6000-813 BY: i//, /.i 'lf!�j�i�I%? ,rs \ �
Deputy Cler to the B: t.�►
Daytime Telephone No. (970) 356-4000 X4200
NOV 0 3 2008FAX Telephone No. (9700 352-0242
L 1195/
Federal Law requires you to furnish your Social Security or Taxpayer Identification Number.
Failure to comply will result in 31%tax withholding and will not be refundable by Payor.
�'unsettf A iJa u/ does Cc PE-t- o-Ga-.ks' itLs$d2,6
PETRO-CANADA RESOURCES INC
Attached to and made a part hereof that
A
Certain Division Order
Effective on Date Shown Herein:
Well/Unit No: 13534 Issue Date: 10/06/08
Well/Unit Name: PERKINS 29-45 Effective Date: First Production
County: WELD Last Change Date: 01/01/08
State: COLORADO D/O Master Ref: 14960
Operator: PETRO-CANADA RESOURCES (USA) I Product: ANY PRODUCT
Original D/O Date:
From Well Master Tract*: 10099
Well/Unit Description:
SE SEC 29-T4N-R68W
Owner Owner Name and Address Type Decimal Pay
Number Taxpayer ID Interest Interest Code
102098 WELD COUNTY BOARD OF COUNTY RI 0.00453111 M
COMMISSIONERS
WELD COUNTY CENTENNIAL CENTER
915 10TH ST
GREELEY, COLORADO 80632
PAGE 1
Pr!
IITRo-w1ADA, Petro-Canada Resources(USA) Inc.
October 6, 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 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.
Sincerely,
PETRO-CANADA RESOURCES� (USA) INC.
JJV
Aubrie M. Smith
Jr. Division Order Analyst
Aubrie.Smith oPpetro-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 applicable.
Coun Attorney
DATE: G O e
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