HomeMy WebLinkAbout20001770 NADOA Model Form Division Order(Adopted 9/95),
DIVISION ORDER
To: Prima Oil &Gas Company ® /� Date: July 14, 2000
1801 Broadway, Suite 500 YOUR COPY Effective Date: First Production
Denver, CO 80202
Property Number: 003004
Property Name: Scottdale 26-43
Operator Prima Oil & Gas Company
County and State: Weld County, Colorado
Property Description: T4N, R67W, 6th P.M., Section 26: W/2SE/4
Production: X Oil _X Gas Other
Owner Name and Address: OWNER NUMBER:
SEE EXHIBIT"A"ATTACHED HERETO
Type of Interest:
Decimal Interest:
The undersigned certifies the ownership of their decimal 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, 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
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 statue.
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
Owner(s)Signature: B t2,(LC /X-ty
arbara J. Kir meyerV Chair (07/19/2000),
Owner(s) Tax ID Number(s) 84-6000-813 ,ti pr
Owner Daytime Telephone#: (970)356-4000 X4200 Witness: � i[.-,.� ► .h✓�3t::c::�!�'�'
o t • B•c,
Owner FAX Telephone#: (970)352-0242 Witness: i.. . <✓i -/1
Deputy Clerk to t %
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.
LCD/5=2
2000-1770
EXHIBIT"A"
Division of Interest for Scottdale 26-43
Owner No. Name&Address
Interest Owned Decimal Interest
Royalty Interest
107097 Ethel V.Rediess Revocable Trust dtd 9-7-94 33.333334%x 12.5%x 19.245/80= 0.01002344
1544 9th Street
Alameda,CA 94501
107113 John A Andrews 25.0%x 33.333333%x 12.5%x 19.245/80= 0.00250586
6301 Jo Ann Place NE
Albuquerque,NM 87109
107114 James D.Andrews 25.0%x 33.333333%x 12.5%x 19.245/80= 0.00250586
7531 Solarset Circle
Anchorage,AK 99507
107115 Anna Mae Pyle 25.0%x 33.333333%x 12.5%x 19.245/80= 0.00250586
13965 Corene Road
Sterling,CO 80751
107112 Mary Louise Smylie 25.0%x 33.333333%x 12.5%x 19.245/80= 0.00250586
925 Smylie Road
Douglas,WY 82633
107096 Jess Paul Andrews 50.0%x 33.333333%x 12.5%x 19.245/80= 0.00501172
303 Washington Street
Baldwin City,KS 66006-5053
107095 Estate of Ruth Helen Renz 50.0%x 33.333333%x 12.5%x 19.245/80= 0.00501172
2055 Vista Grande Drive
Austin,CO 81410
103435 S Ranches,Pt Inc.
25.0%x 12.5%x.227/80+
do Dr.Michael Ptasnik 25.0%x 12.5%x 47.130955/80= 0.01849920
4815 S.Vine Street
Englewood,CO 80110
107558 Tom Sharkey 25.0%x 12.5%x.227/80+
15430 Copperfield Drive 25.0%x 12.5%x 47.130955/80= 0.01849920
Colorado Springs,CO 80921
103499 Sandra M.Reid,f/k/a Sandra Purse Hughes 25.0%x 12.5%x.227/80+
117 Poipu Drive
25.0%x 12.5%x 47.130955/80= 0.01849920
Honolulu,HI 96825
103436 Benson Mineral Group,Inc.
19.637277%x 12.5%x.227/80+
Dept. 161 19.637277%x 12.5%x 47.130955/80= 0.01453096
Denver,CO 80271
103437 BWAB Incorporated Sud
2.50%x 12.5%x.227/80+
475 17th Street,Suite 1390 2.5%x 12.5%x 47.130955/80= 0.00184992
Denver,CO 80202
103438 John R.Wallace 0.954241%x 12.5%x.227/80+ 0.00070611
475 17th Street,Suite 980 0.954241%x 12.5%x 47.130955/80=
Denver,CO 80202
LSD/5.3
Page 1 of 3
Division of Interest for Scottdale 26-43
Owner No. Name&Address Interest Owned Decimal Interest
103439 James D.Brownlie 0.954241%x 12.5%x.227/80+ 0.00070611
475 17th Street,Suite 980 0.954241%x 12.5%x 47.130955/80=
Denver,CO 80202
103441 Kenneth A.Breitenbach 0.954241%x 12.5%x.227/80+
410 17th Street,Suite 1151 0.954241%x 12.5%x 47.130955/80= 0.00070611
Denver,CO 80202
101123 HS Resources,Inc. 100%x 20.0%x 13.088/80= 0.03272000
Dept.#214-02
Denver,CO 80271
,/ 102187 Weld County Board of County Commissioners 12.5%x.309045/80= 0.00048288
Weld County Centennial Center
915 10th Street
Greeley,CO 80631
Overriding Royalty Interest
104049 SOCO Wattenberg Corporation 3.193750%x 19.245/80= 0.00768296
1625 Broadway,Suite 2000
Denver,CO 80202
106337 Taku Resources,LLC 1.793750%x 19.245/80= 0.00431509
P.O.Box 3190
Littleton,CO 80161-3190
106338 Geronimo Energy Partners,L.L.C. 1.5750%x19.245/80= 0.00378886
P.O.Box 4782
Englewood,CO 80155-4782
103040 Baker Oil Corporation 0.50%x 19.245/80= 0.00120281
P.O.Box 9190
Denver,CO 80209
101525 Barry L.Snyder 0.21875%x 19.245/80= 0.00052623
c/o Aeon Energy Company
7500 W.Mississippi Avenue,Suite B2
Lakewood,CO 80226
100813 Ted E.Amsbaugh&Co. 0.21875%x 19.245/80= 0.00052623
Box 168,RR1
Bottineau,ND 58318
101123 HS Resources,Inc. 7.50%x.227/80+
Dept.#214-02 7.5%x 47.130955/80= 0.04439808
Denver,CO 80271
102850 Eddy Oil Company 7.50%x.309045/80= 0.00028973
1432 South Lansing Street
Aurora,CO 80012
r0/523
Page2of3 �
Division of Interest for Scottdale 26-43
Owner No. Name&Address Interest Owned Decimal Interest
Working Interest
000001 Prima Oil&Gas Company 100%x 80.0%x 13.088/80+
100%x 80.0%x.227/80+
100%x 80.0%x 19.245/80+
100%x 80.0%x.309045/80+
100%x 80.0%x 47.130955/80= 0.80000000
Total 1.00000000
Page 3 of 3 LEC/5 3
INSTRUCTIONS TO INTEREST OWNERS
This instrument should not be altered in any way unless accompanied by documerylary 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
1801 Broadway, Suite 500
Denver, CO 80202
Attention: Marlene Boyle
(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 for legal description, and
percentage of royalties, if applic
BY: /1 I
County me
DATE:
Hello