HomeMy WebLinkAbout20040857 NADOA Mod irm Division Order (Adopted 9/95)
V
DIVISION ORDER
To: Prima Oil & Gas Company Date: February 6, 2004
1099 18th Street, Suite 400 Effective Date: First Production
Denver, CO 80202 AWI o5 - l ;3 - ac57
Property Number: 348013 O
Property Name: Hettinger 24-11 (CODELL FORMATION)
Operator: Prima Oil & Gas Company
County and State: Weld County, Colorado
Property Description: E/2NE/4 (NE/4NE/4) Section 24, T6N-R67W , 6th P. M .
Production: X Oil X Gas X Other
Owner Name and Address: OWNER NUMBER:
SEE EXHIBIT "A" ATTACHED HERETO
Type of Interest: SEE EXHIBIT "A"
Percent Interest: SEE EXHIBIT "A"
The undersigned certifies the ownership of their percent interest in production or proceeds as described
on Exhibit "A" payable by Prima Oil & Gas Company (Payor).
Payor shall be notified, in writing, of any change in ownership, percent 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
reimburse Payor any amount attributable to an interest to which the undersigned is not entitled .
Payor may accrue proceeds until the total amount equals $25.00, or pay once a year whichever occurs
first, or as required by applicable state statute.
This Division Order does not amend any lease or operating agreement between the undersigned and the
lessee or operator or any other contracts for the purchase of oil or gas.
In addition to the terms and conditions of this Division Order, the undersigned and Payor may have
certain statutory rights under the laws of the state in which the property is located.
Special Clauses:
( � I_ ♦ proter
MAR
Owner(s) Signature: � �, 1� & d I Cuun y uum1oiuners
A E
Owner(s) Tax ID or Social 200it Security #. 84-6000-8 � .,: � , •�� .
Idb NII r . .� •.crr i� / /i.N
Owner Daytime Telephone #: ( 970) 356-4000 � ?�?`: ` ' OUNTY C! f:,"'KC TOTH • BOARD
Owner FAX Telephone #: ( 970 352-024204, /i/L- l
I Y CLERK U I HE BOARD
Address: 915 10th Street . P . 0 . Box 75$,� 4s , - .n1nrado 80637
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.
YOURCopy 2004-0857
RR V
P F.POET NO: GIB1SO EXHIBIT "A" PACE NO 1
RUN DATE : 02/06/2004 TIME: 10:56:42
DETAIL
SEC: DOI
DIVISION ORDER NO: 348013 TITLE: HETTINGER 24-13
348013 HETTINGER 24-11
INT. EFFECT. EFFECT. AEC DIST CRE SOS WPT ST EXEMPT PAY
OWNER NO/NAME TYPE DATE TO DESCRIPTION PERCENT REV BILL ENT CUE CDE 1 2 3 4 5 TO
000001 PRIMA OIL & GAS COMPANY WI 05/01/2002 12/01/9999 OIL 80.166657 Y Y Y 00 NNNNN
1099 18th STREET SUITE 400 NO NET A/R GAS 80.166657 Y Y Y 00 NNNNN
DENVER CO 80202 AD VALOREM 80.166657 Y Y Y 00 NNNNY
LEASEHOLD 99.000000 N Y
BEFORE CASI 99.000000 N Y
AFTER CASIN 99.000000 N Y
OPERATING C 99.000000 N Y
102326 HOWARD & ASSOCIATES LTD ORRI 05/01/2002 12/01/9999 OIL 0.871343 Y Y Y 6 00 NNNNN
10927 ORAL ZUMWALT WAY GAS 0.871343 V Y Y 6 00 NNNNN
MISSOULA MT 59803 AD VALOREM 0.871343 Y Y Y 6 00 NNNNN
103348 BLUE CHIP OIL INC WI 05/01/2002 12/01/9999 OIL 0.875000 Y Y Y 1 CC NNNNN
19 OLD TOWN SQUARE NO NET A/R GAS 0.875000 Y Y Y 1 CO NNNNN
FORT COLLINS CO 80524 AD VALOREM 0.875000 Y Y Y 1 00 NNNNN
LEASEHOLD 1.000000 Y Y
BEFORE CASI 1.000000 Y Y
AFTER CASIN 1.000000 Y Y
OPERATING C 1.000000 Y Y
104 ELD COUNTY RI 05/01/2002 12/01/9999 OIL 0.125000 Y Y Y 1 00 NNNNN
DEPARTMENT OF PLANNING AND ZONING GAS 0.125000 Y Y Y 1 00 NNNNN
1555 N 17TH AVE AD VALOREM 0.125000 Y Y Y 1 00 NNNNN
GREELEY CO 90631
107379 CRAIG HARRISON RI 05/01/2002 12/01/9999 OIL 2.614031 Y Y Y 1 00 NNNNN
2725 ROCKY MOUNTAIN AVENUE, STE 400 GAS 2.614031 Y Y Y 1 00 NNNNN
LOVELAND CO 80538 AD VALOREM 2.614031 Y Y Y 1 00 NNNNN
107380 BOYD MEYER RI 05/01/2002 12/01/9999 OIL 0.868247 Y Y Y 1 00 NNNNN
P O BOX 82 GAS 0.868247 Y Y Y 1 00 NNNNN
WINDSOR CO 80550 AD VALOREM 0.868247 Y Y Y 1 00 NNNNN
107606 WILMA IRENE HETTINGER RI 05/01/2002 12/01/9999 OIL 3.532578 Y Y Y _ 00 NNNNN
3500 CARLTON AVENUE #045 GAS 3.532578 Y Y Y 1 00 NNNNN
FT. COLLINS CO 80525-5715 AD VALOREM 3.532578 Y Y Y 1 00 NNNNN
107607 W. LEE DETT£RER RI 05/01/2002 12/01/9999 OIL 1.429687 Y Y Y 1 00 NNNNN
31815 WELD COUNTY ROAD 23 3/4 GAS 1.429687 Y Y Y 1 CO NNNNN
GREELEY CO 80631 AD VALOREM 1.429687 Y Y Y 1 00 NNNNN
109833 MICHAEL J. DESHAZO RI 05/01/2002 12/01/9999 OIL 1.712972 Y Y Y 1 00 NNNNN
CAROLYN L. DESHAZO, J/T GAS 1.712972 Y Y Y _ 00 N N N N N
12000 HIGHWAY 392 AD VALOREM 1.7129'2 Y Y Y 1 OD NNNNN
GREELEY CO 80631-9357
109843 ZODIAC LIMITED PARTNERSHIP ORRI 05/01/2002 12/01/9999 OIL 2.119547 Y Y Y 1 00 NNNNN
BY: COSMIC CORPORATION, GEN PARTNER GAS 2.119547 Y Y Y 1 00 NNNNN
1811 25TH AVENUE AD VALOREM 2 119547 Y Y Y 1 CO NNNNN
GREELEY CO 80631
109843 ZODIAC LIMITED PARTNERSHIP RI 05/01/2002 12/01/9999 OIL 5.652125 Y Y Y 1 CO NNNNN
BY: COSMIC CORPORATION, GEN PARTNER GAS 5.652125 Y Y Y 1 00 NNNNN
1811 25TH AVENUE AD VALOREM 5.652125 Y Y Y 1 00 NNNNN
GREELEY CO 80631
110124 GARTH E. CHURCHES RI 05/01/2002 12/01/9999 OIL 0.032813 Y Y Y 1 00 NNNNN
12002 HIGHWAY 392 GAS 0.032813 Y Y Y 1 00 NNNNN
GREELEY CO 80631 AD VALOREM 0-032813 Y Y Y 1 00 NNNNN
RUN NO: 310150 EXHIBIT KA17 PAGE NO. 2
ROIl DATE : 02/06/2004 LA u TIME: 10-56 42
DETAIL
SRO, DOI
DIVISION ORDER NO. 348013 TITLE: HETTINGER 24-11
INT. EFFECT. EFFECT. REC DIST CRE SUS WPT ST EXEMPT PAY
OWNER NO/NAME TYPE DATE TO DESCRIPTION PERCENT REV BILL ENT CDE CDE 1 2 3 4 5 TO
NET NET REVENUE INTEREST NET 00/00/0000 12/31/9999 OIL 100.000000
GAS 100.000000
AD VALOREM 100.000000
TOTALS PRODUCTS WORKING NET WI NET REV ROYALTY OVERRIDES WI+RI+OR EXPENSES
OIL 81.041657 100.000000 81.041657 15.967453 2.990890 100.000000 LEASEHOLD 100.000000
GAS 81.041657 100.000000 81.041657 15.967453 2.990890 100.000000 BEFORE CASING POINT 100.00 COO
AFTER CASING POINT 100.000000
OPERATING COSTS 100.000000
AD VALOREM 81.041657 100.000000 81.041657 15.967453 2.990890 100.000000
Weld County Planning Departs
GREELEY OFFICE
INSTRUCTIONS TO INTEREST OWNERS FEB 9 9 200'l
(DIVISION ORDER)
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 since it reflects record title. If 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,
certified copy of his authority must be furnished (if not already furnished).
6. If signature is that of an officer of a corporation, signature must be attested, title of signatory
party shown and corporate seal affixed.
7. Verify address to which checks are to be mailed and make corrections if necessary. (If
subsequent change of address is necessary, please notify us promptly, including your Owner
Number, which appears on your check).
8. 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.
Prima Oil & Gas Company
1099 18th Street, Suite 400
Denver, CO 80202
Attention: Janet L. Frase
(303) 297-2300
Checks will be issued by our accounting department monthly upon receipt of the fully executed Division
Orders. They are normally mailed out around the 20th of each month. However, funds will be held until
they total$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.
c_
BY:
Coun orney
DATE: -� /5 k
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