HomeMy WebLinkAbout990637.tiff •
OIL AND GAS DIVISION ORDER
OPERATOR: HS RESOURCES, INC. Date: MARCH 22, 1999
1999 BROADWAY,SUITE 3600 Effective Date: CURRENT PRODUCTION
DENVER, CO 80202 Well Number: 920421
(303)296-3600
Well Names: HSR EIN #6-20A Copy
Description: T3N R66, SEC. 20: N12
Formation: "J" SAND
County and State:WELD COUNTY,COLORADO
Owner: SEE EXHIBIT 'A'ATTACHED HERETO AND MADE A PART HEREOF
Decimal Interest: SEE EXHIBIT 'A'ATTACHED HERETO AND MADE A PART HEREOF
The undersigned certifies the ownership of the decimal interest in production or proceeds as described above payable by HS RESOURCES, INC.
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 clay 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 referred to herein the amount of any tax
placed thereon by any governmental authority and to pay the same on our behalf. ;,�,^fit\
Wi sl a v l u?
Owner(s)Signature(s): �►x4/L ri A& • MINI`/ \
Dale K. Hall, Chair (03/29/99) `. y/�
Owner(s)Tax I.D.# 84-6000-813 •
Deputy Clerk to :.,
Owner Daytime Telephone#_ (970) 356-4000
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.
P1IPl='OrrTED COPY
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2683507 03/31/1999 09:32A Weld County CO Let 044
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COUNTY ATTORNEY
STAFF APPROVAL
This is to affirm the attached
Division Order or 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.
9
Jj
BY: �,-
/ nty Attorney
DATE:
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