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NADOA Model l• _ . n. .iivision Order (Adopted 9/95)
DIVISION ORDER
To: Weld County Board of Date: 08-08-2006
Commissioners
Property Number: Pronghorn #43-15 Effective Date: First Date of Production
Property Name: Lease No.:
Operator: Bonanza Creek Energy Operating Company, LLC /1 p' 05- / 2 3 - z 3777
County and State: Weld County, Colorado !�
Property Description: NE/4 SE/4 of Section 15, T-5N, R-61W, Weld County, Colorado
Production: Oil Gas Other:
Owner Name Weld County Board of Commissioners OWNER NUMBER: W1003
And Address: P.O. Box 758
Greeley CO 80632 Type of Interest: RI
Decimal Interest: 0.125000000
The undersigned certifies the ownership of their ownership of their decimal interest in production or proceeds as described above
payable by Bonanza Creek Energy Operating Company, LLC (Payor).
(Company Name)
Payor shall be notifed, in writing, of any change in ownership, decimal interest, or payment address. As 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 Twenty-Five Dollars , or pay N/A 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:
Weld Cou oard of Commissioners
Owner(s) Signature(s):
�� Alr JG 2 8 2006
M. J . eile , Chair
Owner(s) Tax I.D. Number(s) 84-6000-813
Owner Daytime Telephone #: ( 970) 356-4000 X4200
Owner Fax Telephone #: ( 970 ) 352-0242
o ft`Federal Law requires you to furnish your Social Security of Taxpayer Identification Number. I
1 ,,k. �° It ilure to comply will result in 31 % tax withholding and will not be refundable by Payor.
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p /tI N ,0 5PO CLER 'fTO THE BOARD > EWF/
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BONANZA CREEK. ENERGYOPERATING COMPANY, LLC
CORPORATE OFFICE ROCKY MOUNTAIN OFFICE
4900 Celifurniaa Avenue-Suite 3508 / 410 17"Street.Suite 1380
Baker./ield.C,4 93309 Denver, CO 80202
P.O.&u 21974 BC Office:720-279-2330
8akeerfield,C4 93390 Fax.720-279-2331
ON e: 661/638-2730
Fax: 661/638-2733
August 08,2006
Weld County Board of Commissioners
P.O. Box 758
Greeley, CO 80632
RE: Pronghorn 43-15 Well, NE SE 15-T5N-R6I W
Pronghorn Area, Weld County, Colorado
Dear Royalty Owner:
Enclosed for your signature and review please find duplicate originals of the Oil and Gas Division Order
form, which sets out your interest in the above referenced wells. If any of the information contained
therein is incorrect or incomplete, please make the necessary changes and initial.
Also enclosed for your completion is Form W-9, Request for Taxpayer Identification Number and
Certification. This form is required by the Department of Treasury, Internal Revenue Service and must be
completed before any funds can be released.
Please sign both originals, retain one copy for your records, and return one to the undersigned in
the self-addressed envelope that is provided for your convenience. Note: two other individuals
must witness your signature. Please also return the completed Form W-9 for the completion of our
records.
Should you have any questions or comments, please feel free to contact me by telephone at 661-638-2730
X205. Thank you for your cooperation and assistance in this matter.
Respectfully,
Bonanza Creek Operating Company, LLC
O1/1-^-
Monica L. Ward-Keller
Business Development Coordinator
Enclosures (4)
2006-2354
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For, W-9 Request for Taxpayer Give form to the
(Rev.November2005) Identification Number and Certification requester. Do not
Department al the treasury send to the IRS.
Imemel Revenue Service
r`i Name(as shown on your income tax return)
Weld County, Colorado
co
a Business name,if different from above
c
O
m
o IndividuaV Governmental �I Exempt from backup
Check ❑ proprietor ❑ Corporation ❑ Partnership ] Other ► BttLYtey- withholding
appropriate box: Sole
Address(number,street,and apt.or suite no.) Requester's name and address(optbnal)
915 10th Street
City,state,and ZIP code
Greeley, Colorado 80631
List account number(s)here(optbnao
CO
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box.The TIN provided must match the name given on Line 1 to avoid Social security number
backup withholding.For individuals,this is your social security number(SSN). However,for a resident + +
alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is
your employer identification number(EIN). If you do not have a number, see How 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 guidelines on whose Employer Identification number
number to enter. Slit T'I3 10 101018 I1 [3
Part II Certification
Under penalties of perjury, 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 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 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 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 n page 4.)
Sign Signature of
Here U.S.person ► := Date ► 08/28/2006
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. person.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 rules 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
U.S. exempt payee. withholding tax. Therefore, if you are a U.S. person that is a
partner in a partnership conducting a trade or business in the
In 3 above, if applicable, you are also certifying that as a 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
purposes of establishing its U.S. status and avoiding
Note. If a requester gives you a form other than Form W-9 to
request your TIN, you must use the requester's form if it is partnership
withholding conductingon its allocabletrade share business f net income from the
substantially similar to this Form W-9. partnership a or in the United
States is in the following cases:
For federal tax purposes,you are considered a person if you • The U.S. owner of a disregarded entity and not the entity,
are:
Cat.No.10231X Form W-9 (Rev.11-2005)
:_90t)‘„ - X35 f
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:
Coun om
DATE: / U�
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