HomeMy WebLinkAbout20012738.tiff OIL AND GAS DIVISION ORDER
OPERATOR: HS RESOURCES, INC. Date: August 28,2001
1999 BROADWAY,SUITE 3600 Effective Date: Date of First Production
DENVER, CO 80202 Well Number 610490 e
(303)2964600
Well Name: CLC GU#1
Description: T2N R66W,SEC. 18:S/2
Formation: J Sand(Revised 8/16/01)
County and State: Weld, Colorado
Owner: Address: Decimal Interest:
WEL210 WELD COUNTY BOARD OF 915 10TH STREET 0.00494822 RI
COMMISSIONERS GREELEY, CO 80632
The undersigned certifies the ownership of the decimal interest in production or proceeds as described above payable by HS RESOURCES,INC.
HS RESOURCES, INC.shall be held harmless in the event of, and is hereby released from any and all damage or loss which might arise out of any
overpayment. The Owner executing this Division Order, in consideration of payments by HS RESOURCES,INC.,agrees to pay any overriding royalty
or royalty owners and/or all other persons who may have right, title or interest in the interest in production set out above and further agrees to protect,
indemnify and hold HS Resources, Inc.harmless from and against any and all loss, cost or expense which it may suffer or sustain by reason of such
payment regardless of how any such claim or demand may arise, including all costs or expenses incurred by HS Resources, Inc. in defending its
position in any such claim,suit or action.
The undersigned agrees to notify HS RESOURCES, INC., 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.
HS RESOURCES, INC. 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 HS RESOURCES, INC.any amount attributable to
an interest to which the undersigned is not entitled.
HS RESOURCES, INC. may accrue proceeds until the total amount equals twenty-five dollars($25.00), or pay annually, 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 HS RESOURCES, INC.may have certain statutory rights under the
laws of the state in which the property is located.
The undersigned authorizes HS RESOURCES, INC. to withhold from the proceeds of any and all production referre unt of any tax
placed thereon by any governmental authority nd to pay the same on our behalf.
Witte. s:
Owner(s)Signature(s):
M. J Geile, Chair (09/19/01) _q`
Deputy Clerk to ,•\\ �`���
Owner(s)S.S.or Tax I.D.# 84-6000-813
Owner Daytime Telephone# (970)356-4000 X4200
Owner Fax Telephone# (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 Payor.
2001-2738
EXHIBIT"A"
CLC GU#1
T2N,R66W
SEC.18:Sl2
326.38 ACRES,MIL __ _-- -_—_-.--
J Sand Formation
WELL#610480_
REVISED 8116101
REVISED PRIOR
OWNER F , DECIMAL DECIMAL INTEREST
NUMBER OWNER NAME MAILING ADDRESS INTEREST INTEREST TYPE
---- 9743 WCR 16
BEA776 I DARRELL L.BEARSON AND NELVA M.BEARSON FT.LUPTON,CO 80821 - 0.00294902 0.00269320 RI
36 STEELE ST.#250
CAN566 [CANNON LAND COMPANY_ DENVER,CO 80206 _ _0.07926.727 0.07941770 [ RI
36 STEELE ST.#250
CAN566 CANNON LAND COMPANY DENVER,CO 80206 0.07926727 0.07941760 ORR
P.O.BOX 536 li
6505 E.160TH AVE.
DEG261 MARCUS A.DEGENHART BRIGHTON,CO 80602-6006 ! 0.00033958 0.00033960 ORR _
80 SOUTH 27TH AVENUE
FAR520 FARMERS RESERVOIR&IRRIGATION CO. BRIGHTON,CO 806.01 0.00203750 0.00203760 RI
J.P.FIELD ESTATE 1414 BANK ST.
FIE520 C/O M.F.BOUDREAU,EXECUTOR LAKE CHARLES,LA 70801-6206 0.00013244 0.00013250 RI
GROUND WATER MGMT SUBDISTRICT OF THE -
CENTRAL COLORADO WATER CONSERVANCY 3209 W.28TH ST.
GRO853 DISTRICT _ GREELEY,CO 80634 0.00035618 NO INTEREST RI
8388 WELD COUNTY RD.23
HEI503 RICHARD L.HEIN FORT LUPTON,CO 80621 ` 0.00750391 NO INTEREST RI
6196 S.CARSON ST.
HIL400 BOB HILL _ ENGLEWOOD,CO 80111 ! 0.00033958 0.00033960 ORR
805 MEADOW RUN
HOO852 MATTHEW R.HOOVLER GOLDEN,CO 80403 0.00033958 0.00033960 ORR
HSR001 HS RESOURCES,INC. _ _ _ 0.78186546 0.78173050 NRI
HSR001 HS RESOURCES,INC. 0.01060727 0.01055960 ORR _
JUR326 SHANNON JURGENSEN __ ADDRESS UNKNOWN 0.00207772 0.00207780 RI
129 NORTH 4TH AVENUE
JUR327 EILEEN J.JURGENSEN BRIGHTON,CO 80601 0.00831088 0.00831140 RI
_ I _
P.O.BOX 1109
KEN527 'KEN PERKINS OIL&GAS INC. 'INGRAM,TX 78025-1109 NO INTEREST! 0.00210860 ORR
I P.O.BOX 3248 I
MCC855MCCULLISS RESOURCES COMPANY,INC. LITTLETON,CO 80181-3248 0.0010.3885 0.00103890 '[ RI
BRADY LANDON NELLIS AND CHRISTINE J. 13420 BRAUN RD. I
SMITH,JTS GOLDEN,CO 80401 0.00185941 NO INTEREST RI
ROBERTS FAMILY TRUST 12501 E.104TH AVE.,#1201
ROB274 NORMA JEAN ROBERTS TTEE DENVER,CO 80233 NO INTEREST 0.00371910 RI
;7311 MONROE
SHO770 LOIS G.SHORT [MISSION,TX 7.8572 0.00415543 0.00415570 RI
19378WCR25
STA350 ROBERT M.STAHL AND MARY E.SHAHL,JTS 'FT.LUPTON,CO 80621 0.00350244 I 0.00164860 RI
SUN004 SUN OPERATING LIMITED PARTNERSHIP ADDRESS UNKNOWN 0.00210881 NO INTEREST ORR
P.O.BOX 13557
VAU335 GEORGE G.VAUGHT,JR. 'DENVER,CO 80201-3557 0.00103885 0.00103890 RI
91516TH STREET
WEL210 WELD COUNTY BOARD OF COMMISSIONERS GREELEY,CO 80632 0.00494822 0.00543440 RI
C/O PETERSON MGMNTCO INC.
7586 WEST JEWELL AVE.#202
WEL268 iWELCO VENTURE LAKEWOOD,CO 80235-2309 0.00595433 0.01345910 RI
TOTAL: 1.00000000 ' 1.00000000
Page 1
HS RESOURCES, INC.
1999 BROADWAY, SUITE 3600
DENVER, COLORADO 80202
(303) 296-3600
FACSIMILE (303) 296-3601
INSTRUCTIONS FOR EXECUTION OF OIL AND GAS DIVISION ORDERS
Please read the following instructions carefully before signing the enclosed division order:
1. Be sure that your interest is correct.
2. Sign your name in the space provided exactly as it is shown BEFORE TWO
WITNESSES.
3. Your SOCIAL SECURITY NUMBER or TAX IDENTIFICATION NUMBER must be
shown in the space provided. Failure to provide the number may result in a 31%
withholding of your production proceeds, as required by law, and you also could be subject
to a penalty imposed by the Internal Revenue Service. Also enclosed is an IRS Form W-9,
please complete and return this form so that we will have it for our records. (For new
owners only)
4. Show the address to which checks should be mailed.
5. If the interest is owned by a CORPORATION,the division order must be signed by a duly
authorized officer and attested. The corporate seal must be affixed and the title of the
signing officer shown.
6. If the interest is owned by a PARTNERSHIP, the division order must be signed by the
general partner or managing partner and evidence of such authority to sign must be
furnished.
7. Tf the division order is signed by anyone other than the named owner such as an AGENT,
ATTORNEY-IN-FACT,or GUARDIAN,evidence of authority must be provided.
After you have completed and signed the division order,please return the original to us. The copy is
for your records.
Should you have any questions,please do not hesitate to call.
WENDY HOPKINS
HS RESOURCES,INC.
1999 BROADWAY, SUITE 3600
DENVER,CO 80202
(303)296-3600
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