HomeMy WebLinkAbout20073744.tiff NADOA Model Form Division Order(Adopted 9/95)
DIVISION ORDER
To: Petroleum Development Corporation Date: November 12,2007
1775 Sherman Street, Suite 3000
Denver,CO 80534
Attn: D.O. Analyst
Property Number: 07429 Effective Date: June I, 2007
Property Name: Nelson 42-33 JS
Operator: Petroleum Development Corp.
County and State: Weld,Colorado
Property Township 5 North, Range 67 West
Description: Section 33: SENE
Production: X Oil X Gas X Other: all products
Owner Name OWNER NUMBER:
and Address:
See `Exhibit A' attached hereto and made a part hereof Type of Interest:
Decimal Interest:
The undersigned certifies the ownership of their decimal interest in production or proceeds as described above payable by Petroleum
Development Corporation (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 amount equals$50.00 , or pay yearly 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. ,q �J
Special Clauses: (N or See Attached Exhibit) ,� ,l�2/ �� //. -)
r. >'Ya,'1 ^' ,. e a
Owner(s) Signature(s): David E. Long, C ATTESTS_
hair Clerk to the Board }Ga
EC 1 2 2007
Owner(s)Tax I.D. Number(s): 84-6000-813 _ BY: V � DI
Dep y C1 k to the 1440.:77-, (��
Owner Daytime Telephone 970-356-4000 X4200 _ ( �� °�
Owner FAX Telephone It: 970-352-0242
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 Payer
G Retain this copy for your records L�L7DO
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Exhibit A
07429-Nelson 42-33 JS
Owner No. Credit To Type Interest
43444 Weld County Brd Of Comm RI 0.00042188 << Your Interest
PO Box 758
Greeley, CO 80632-0000
INSTRUCTIONS TO ALL INTEREST OWNERS
Dear Interest Owner,
Petroleum Development Corporation has enclosed a Division Order for your execution.
The attached document should not be altered in any way except to correct spelling errors, unless accompanied by
documentary evidence to support the change.
If your name and interest are correctly shown:
I. Sign your name as shown on the Division Order.
2. If your name has changed due to marriage or divorce, execute the Division Order using your present name and furnish a copy
of the marriage certificate or divorce decree.
4. If signing for a corporation, signature must be attested, corporate seal fixed and title of signatory party reflected.
5. If signed by agent, attorney-in-fact, guardian or any party other than the named interest owner, a certified copy of the power
of attorney or other evidence of such party's right to sign must be furnished.
6. Your correct mailing address should be noted in the space provided to insure prompt receipt of production proceeds.
7. The top copy or the"Original"of the Division Order should be returned to:
Petroleum Development Corporation
1775 Sherman Street, Suite 3000
Denver, Colorado 80203
Attn: Division Orders
8. Should you have any further questions regarding the enclosed Division Order, please contact Petroleum Development
Corporation at(303) 860-5836 or(888) 860-5836.
9. Please DO NOT DETACH the exhibit from the Division Order or Transfer Order if one is included.
2007-3744
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