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Home My WebLink About20230706.tiffChevron %.1 December 28, 2022 U SPS Certified Mail Article #7014 0640 0003 4996 2697 Weld County Colorado Board of County Commissioners PO Box 758 Greeley CO 80631 RE: After -Payout Status Payment IRS W-9 and Chevron Vendor Taxability Assessment Form Request Dear Owner: RECEIVED JAN 09 2023 WELD COUNTY COMMISSIONERS Noble Energy, Inc.'s ("Noble") records indicate that certain well(s) you have an interest in have paid out. Due to a clerical oversight, your interest was not placed into an after -payout status. Noble has adjusted its records to have your interest placed in active status as of the well pay out date. In order to send an after -payout payment, Noble will need the attached documentation completed: • IRS W-9 Form • Chevron Vendor Taxability Assessment Form Within forty-five (45) days following receipt of the completed documents and upon review, Noble will forward an after -payout check. Enclosed you will find a pre -addressed, postage paid envelope for your convenience. P lease contact Rachel Edwards at 303-228-4345 or racheledwards@chevron.com should you have any questions or wish to discuss further. S incerely, eac./zal &/&a'Ij Rachel Edwards Land Representative conaLO,\-- uAowN. QI3/‘/23 L-45,14,1-0-xY 8 025 Chevron Rockies Business Unit Noble Energy, Inc. 2001 16th Street, Suite 900, Denver, CO 80202 Tel 303-228-4345 racheledwards@chevron.com 2023-0706 W-9 Identification Request Number for Taxpayer and Certification Give Form to the requester or State Department. Do not send to the IRS. Form (Rev. May 2019) State of Colorado Substitute ► Go to www.irs.govlFormW9 for instructions and the latest information. Print or type. See Specific Instructions on page 3. 1 Name (as shown COUNTY on your income OF WELD tax return). Name is required on this line; do not leave this line blank 2 Business name/disregarded entity name, if different from above 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the 4 Exemi tons (codes apply only to following seven boxes. certain entities, not individuals; see instructic ns on page 3): ❑ Individual/sole proprietor or II C Corporation S Corporation IIPartnership TrusUestate single -member LLC Exempt payee code (if any) ❑ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ► Note: LLC Check if the the appropriate LLC is classified box in the line above as a single -member for :he tax classification of the single -member owner Do not check LLC that is disregarded from the owner unless the owner of the LLC is Exemption from FATCA reporting another LLC that is not disregarded from the owner foe U S. federal tax purposes. Otherwise, a single -member LLC that code (if any) is disregarded from the owner should check the appropriate box for the tax classification of its owner. Other (see instructions) ► ✓ Government (Applies to azcounts maintained outside the U S.) 5 Remittance 1150 address (number, "O" STREET street, and apt/suite or PO Box). See instructions. Procurement address if different (optional) 6 City, state, GREELEY, and ZIP code CO 80632 7 Contact name and email Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid r Social security number backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later. Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter. Part II or Employer identification number Certification 8 4 6 0 0 0 8 3 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 n -e); 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 fh as notified me that I am no longer subject to backup withholding; and 3. I am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to bdr-kup 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 mortge. a interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), a I i 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 for Part II, later. Sign Here Signature of U.S. person ► 41/z/kr General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9. Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. • Form 1099-INT (interest earned or paid) Date ► January 3, 2023 • Form 1099-DIV (dividends, including those trim stocks or mutual funds) • Form 1099-MISC (various types of income, pzes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales anc :ertain other transactions by brokers) • Form 1099-S (proceeds from real estate trans lotions) • Form 1099-K (merchant card and third party -?twork transactions) • Form 1098 (home mortgage interest), 1098-E student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (i icluding a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requeste- with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat. No. 10231X Form W-9 (Rev. 5-2019) • POLITICAL SUBDIVISION SALES TAX EXEMPTION CERTIFICATE (For use by States, Territories or Political Subdivision thereof, or the District of Columbia) The undersigned hereby certifies that he is the Controller of Weld County Government and that he is authorized to execute this Certificate and that all taxable articles/services purchased from are for the exclusive use of Weld County Government, State of Colorado. It is understood that the exemption from tax in the case of sales of articles under this Exemption Certificate to the State, Territory, or Political Subdivision or District of Columbia is limited to the sale of articles purchased for their exclusive use, and it is agreed that if articles purchased tax-free under this Exemption Certificate are used otherwise or are sold to employees or others, such fact must be reported to the manufacturer or the articles covered by this Certificate. It is also understood that tie fraudulent use of this Certificate to secure exemption will subject the undersigned and all parties making use of this Certificate to all applicable criminal penalties under the Internal Revenue Code. COLORADO SALES TAX CERTIFICATION OF EXEMPTION NUMBER - 98-03551-0000 FEDERAL TAX EXEMPTION NUMBER - 84-6000813 STATE TAX IDENTIFICATION NUMBER - 14-02101 By Controller Colorado statute exempts from state and state -collected sales tax all sales to the United States government and the State of Colorado, it's departments and institutions, and it's political subdivisions (county and local governments, school districts and special districts) in their governmental capacities only. {C.R.S. 39-26-114)1)(a)(I)}. Some governmental entities have a Colorado -issued tax -exemption number, although they are not required to have one. Following is a copy of Weld County Government's most recent Colorado -issued Certificate of Exemption for S3 es and Use Tax Only. DR 0160 (02/16/11) COLORADO DEPARTMENT OF REVENUE DENVER CO 80261-0013 THIS LICENSE IS NOT TRANSFERABLE CERTIFICATE OF EXEMPTION FOR STATE SALES/USE TAX ONLY USE ACCOUNT NUMBER for all references LIABILITY INFORMATION ISSUE DATE 09803551 G 010181 Feb 15 2022 G 010181 COUNTY OF WELD PO BOX 758 GREELEY CO 80632-0758 Executive Director Department of Revenue VENDO J N O TAXABILITY ASSESSMENT FORM NOTICE TO ALL CHEVRON PAYEES Chevron 1111 11110 U.S. Federal Tax law provides that payments for certain U.S. sourced, fixed or determinable annual or periodic (FDAP) income, made to payees classified as foreign vendors (non -US) are generally subject to a 30% withholding tax. In addition, California Tax Law provides that payments for certain California sourced income, made to non -California resident payees, are subject to a 7% withholding tax and Pennsylvania Tax Law provides that payments made to certain payees of Pennsylvania sourced income and lessors of Pennsylvania real estate are subject to withholding at a 3.07% rate. Pursuant to such laws, Chevron is required to withhold at maximum withholding tax rate from our payment unless you provide the appropriate Internal Revenue Service (IRS), California Franchise Tax Board (FTB), and Pennsylvania Department of Revenue (DOR) form(s). To reduce and/or eliminate Chevron's tax withholding obligation for failing to properly withhold when required, it is important that we identify those payees that are potentially subject to withholding and collect from them appropriate withholding certificate and other documentary evidences that eliminates our tax withholding obligation. Please complete this Taxability Assessment Form to determine the taxability of your transactions with Chevron and identify the IRS, California, and Pennsylvania tax forms you need to provide to us. Kindly submit the following scanned documentation via e-mail (preferred), fax or snail mail to your Chevron contact person or to the contact information and address found below, once you have completed this Form: • Summary of the result of this Taxability Assessment Form — this is the PDF file generated at the end of the survey. • Requested tax forms, as indicated in the tax assessment result. If you fail to provide valid documentation, payments to your business will be subject to the maximum tax rate applicable, on the entire invoice amount. Please ensure to complete the requirements correctly. Should you have questions or concerns regarding this Form, please contact our Tax Team: E-mail: wtaxcompliance@chevron.com Phone: 925-827-7744 Note IRS Circular 230 Disclosure: Chevron Corporation, its affiliates, and its employees are not in the business of and will not engage in providing tax or legal advice to any person, affiliation, or entity unrelated to Chevron Corporation and its affiliates. Accordingly, any discussion of U.S. tax matters in this document, is not intended or written to be used, and cannot be used, for the purpose of (i) avoiding tax penalties or (ii) promoting, marketing or recommending to another party any transaction or matter addressed herein. Thank you for your cooperation. Tax Compliance Team Chevron U.S.A. Inc. North America Finance Shared Services Center PO Box 6043 Sec 862 San Ramon, CA 94583 Fax 1 925 680 3778 References: • IRS Website: o NRA - http://www.irs.gov/instructions/iw8/ch0l .html o FATCA - http://www.irs..gov/Businesses/Corporations/Foreign _Account-Tax-Compliance-Act-FATCA • FTB Website: https://www.ftb.ca.gov/individuals/wsc/withholding.shtml • PA Website: http://www.revenue.pa.gov/GeneralTaxlnformation/Tax%20Types%20and%201nformation/NonresidentWithholdi Pages/defau It.aspx Revised 04.20.2020 YEN tO . TAXABILITY 1_LITY ASSESSMENT FORM Chevro I�i J This document must be completed by the payee as a declaration of the payee's compliance status with the Vendor Master Account set-up and Tax Compliance Requirements. Complete all applicable sections and submit to your Chevron contact or requesting business unit. I. Vendor General Information 1. Payee's Name: acd C Lt\d Coar1 cW\rys\Q�i 5 S 2. Doing Business As: ka0 C d COLL7filt\I GO VQS c..>CVN 3. Preparer's Name: aCSJ 4 '" CTVB 04% Phone number: '406 - a\ (country code + area code + telephone number) E-mail address: C, c* -- p -h \ConelS kt.C.t.S1 r\ 4. Contact Person for Billing Inquiries: [XI c,.oe.Ado v Co inr\ Put an (X) in this box if the information is similar to the preparer above and skip to number 4. Otherwise, provide the information below. Name (person or group): Phone number: E-mail address: (country code + area code + telephone number) 5. Permanent Residence Address: 150 O S1/4stsik , Gi es_kci 6. Entity type (please select one box): ❑ Individual ❑ Limited Liability Company ❑ Tax-exempt Organization ❑ Trust El Corporation Limited Liability Partnership ❑ International Organization ❑ Estate Co eisoc\ ❑ Partnership frit-Government ❑ Central Bank of Issue ❑ Others (please specify): 7. Country of incorporation (for businesses), country of residence for (individuals) or country of office base (for International Organizations): United States 8. Foreign (Non -US) Tax Identifying Number (TIN): N/A ll. Income Types and Source Answers must be based on the over all op•tration of "pur busin;ss. not oat. on the current contract v itia Chevron. I For US Payee Lit vou_are a_foreitin_pavee. disrecard the table helowiand Qr�Qcee to number 2): In the location section, please put an (X) mark on the box that corresponds to your answer. For income types that do not apply to your business, please leave the row blank. Not:: Pkase provide attestation fir both locatioas — California & Penns\ i•, ania based on >our applicable income type. Type of Income Source or Factor Determining Location Within California Outside California Within I ennsvIvania Outside Pennsylvania Sale of Goods (fuel, materials, equipment, sale of software, sale of resale goods, etc.) Where sold or delivered? ❑ ❑ ❑ ❑ Service Fees (consultation, installation, shipping, product customization, trainings, ngs, etc.) Where physically .. performed? ❑ ❑ ❑ ❑ Rent of real and movable properties (equipment or building) Where property is used or located? ❑ ❑ ❑ ❑ Royalties from Natural Resources Where property is located? Colorado ❑ `, ❑ ` Royalties from Patents, Copyrights, etc. Where property is used? ❑ ❑ ❑ ❑ Royalties from Software Licenses Location of the server where software is installed? the ❑ ❑ ❑ Others (please specify): Where income is derived? ❑ ❑ ❑ ❑ Revised 04.20.2020 VENDOR T1 ),.XAI IIII,II^Y ASSESSMENT FORM Chevron 2 For NON -US Payee ui.tiou are US ooat e_e d isrvczcird the table belo'\. l ou arQQ l required tq.ansvber Pat .11 number 1 ahcneJ In the location section, please put an (X) mark on the box that corresponds to your answer. For income types that do not apply to your business, please leave the row blank. For income derived "within the U.S.A." or "both within and outside the U.S.A.", please also complete the last two columns. Note: Pl-: se provide attestation for all I' ition• (r�itl�in_th; t S. outside the l.S or both) inrlutding California �� Penns‘ based on \c,ur ;applicable income t`., e. _ \sow- ;applicable Location Including the Source or Determining Factor Outside t:.S.A. the Within the U.S.A. Both nithin and outside 1 .S.A. Including the State of California? State of Pennsylvania? Sale of Goods (fuel, materials, equipment, sale of software etc.) Where sold or delivered? ❑ ❑ ❑ ❑Yes No ❑Yes No Service Fees (consultation, installation, shipping, product customization, etc.) Where physically ❑ ❑ ❑ ❑Yes No ❑Yes No performed? Rent of real and movable properties classified as operating lease (equipment or building) Where property is used or located? ❑ ❑ ❑ ❑ Yes ❑ No ❑ Yes ❑ No Royalties from Natural Resources Where property is located? ❑ ❑ ❑ ❑ Yes ❑ No ❑ Yes ❑ No Royalties from Patents, Copyrights, et Where property is used? ❑ ❑ ❑ ❑Yes ❑ No ❑ Yes ❑ No Royalties from Software Licenses Location of the server where the is installed? ❑ ❑ ❑ ❑ Yes ❑ No ❑ Yes❑ No software Interest and Interest Equivalents Location of payors? ❑ ❑ ❑ ❑ Yes ❑ No ❑ Yes ❑ No Dividends and Dividend Equivalents Where Issuer is organized? ❑ ❑ ❑ ❑Yes No ❑Yes No Payments in connection with forwards, futures, options, notional principal contracts, or similar financial instruments The location of the office to where the income is ❑ ❑ ❑ ❑ Yes ❑ No ❑ Yes ❑ No attributable? Premiums for insurance contracts or annuity contracts Location of risk? ❑ ❑ ❑ Investment advisory, custodial, bank, Where services physically brokerage fees, and commissions ❑ ❑ ❑ ❑Yes No ❑Yes No performed? Rent of real and movable properties classified as finance lease (equipment or building) Where property is used or located? (J ❑ ❑ 1 IYes ❑No UYes F iNo Others (please specify): Where income is derived? II Q I ❑Yes No ❑Yes No III. Tax Forms Required (Section IV contains the guide and URL links to the copies of the tax forms.) If you are a US p:a%et.c, please submit the completed and signed Form W-9, and if you answered: 1. "Within California" in Section II, please submit either a California Form 590 or 587, whichever is applicable to your business. 2. "Within Pennsylvania" in Section II, please submit a Pennsylvania Form Rev -1832. If you are a \ O\ t S 1 y, cy and you answered "Within the U.S.A." or "Both within and outside the U.S.A." in Section II, please submit the completed and signed Form W-8. _If you answered "Including the State of California" or "Including the State of Pennsylvania" in Section II, please submit the applicable_California tax form and Pennsylvania Form Rev -1832, Revised 04.20.2020 YEN O IV. Guide to Forms: TAXABILITY ASSESSMENT OM Chevron on Tax Form Applicable Entity Type Guidelines Links W-8EXP Foreign Governments, Foreign Tax Exempt Organizations and Foreign Private Foundations The entity must be claiming exemption under Blank Copy: http://wtiwv.irs.eov/pub/irs- IRS code 115(2), 501(C), 892, 895 or p.df/fw8exp.odf 1443(b). Otherwise submit a W-8BEN or W- 8ECI. Instructions: http://www.irs.gov/pub/irs- p_df/iw8exppdf W-8IMY Foreign Partnerships, Trust and Intermediaries Copies of appropriate withholding Blank Copy: htto://www.irs.gov/pub/irs- certificates, documentary evidence, and pdf/fw8imy.pdf withholding the W-8IMY statements must as well. be attached to Instructions: http://www.irs.gov/pub/irs- pdf%iw8irnv odf W-8ECI - The type of income must be on Line 11 of Blank Copy: http://www.irs.gov/pub/irs- Foreign entities U.S. Tax ID with and U.S. U.S. business address, Income Tax Return the form to qualify for exemption. If it is not pdf/fw8ecdf listed we are required to obtain from the entity a different type of W8 form. Instructions: http.//wwwirs.gov/pub/irs- pdf/iw8eci.pdf - U.S. tax for exemption identification number from tax withholding. is required W-8BEN - A U.S. tax identification number is required Blank Copy: http://www.irs.gov/pub/irs- Individuals establish claiming FACTA foreign status or status treaty and to benefits for exemption from tax withholding. pdf/fw8ben.pdf - All fields in Line 09 must be completed to Instructions: httQ://wwwirs:.gov/pub/irL- claim exemption on Royalty payments. pdf/iw8ben.pdf - Individuals not eligible for forms should use the W-BBEN. the other W8 W-8BEN-E Entities claiming foreign status, and to establish FACTA status or treaty benefits - A U.S. tax identification number is required Blank Copy: http://www.irs.gov/pub/irs- for exemption from tax withholding. pdf/fw8bene.pdf - Entities not eligible for the other W8 forms Instructions: http://www.irs.gov/pub/irs- should use the W-8BEN-E. pdf/iw8bene.pdf Foreign or US entities or individuals to do business or is residing in California. registered - For entities with but is registered non -California to do business addresses in that state, it Blank Copy: https://w'w'vv.ftb.ca.gov/forms/2020/2020- Form 590 is preferable to indicate the California SOS 590.pdf number instead of the FEIN. Foreign or US entities/individuals rendering - Identify apply in PART III the to your business. If all transactions that income are Blank Copy: https://ww'v.ftb.ca.eov/fonns/2020/2020- Form 587 services within the United States. derived outside of California, payments will 587_pdf not be subject to the 7% withholding tax. Foreign or US entities payments from within or the individuals United receiving States. - All entities/individuals are still required to Blank copy with instructions: Form Rev -1832 complete and submit this form. http://www.revenue pa.gov/FormsandPubli cations/FormsforIndividuals/PIT/Document s/rev-I832,pdf US entities or individuals - All US entities/individuals are required to Blank copy with instructions: Form W-9 complete and submit the form. tit. //www.irs.gov/pub/irs-pdf/fw9.pdf 1 Upon receipt of your tax form(s) or attestation, we will review it for accuracy and completeness and conduct our due diligence. We may require additional documentation based on the information provided on the tax form. Once we confirm that the document(s) is(are) complete and valid, we can implement the correct treaty or other special rates and conditions. IV. Certification Under penalties of perjury, I hereby certify that the information provided in this document is, to the best of my knowledge, true and correct. If there will be a change in circumstances, I will promptly notify the withholding agent within 30 days from the date of change. n_3-te„a. Signature over Printed Name Mike Freeman, BOCC Chair MAR 1 3 2323 Board of Weld County Commissioners Date Signed Position/Capacity in which Acting Revised 04.20.2020 Form W-9 (Rev. 10-2018) Page 2 By signing the filled -out form, you: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and 4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting, later, for further information. Note: If you are a U.S. person and 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 substantially similar to this Form W-9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: • An individual who is a U.S. citizen or U.S. resident alien; • A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States; • An estate (other than a foreign estate); or • A domestic trust (as defined in Regulations section 301.7701-7). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax under section 1446 on any foreign partners' share of effectively connected taxable income from such business. Further, in certain cases where a Form W-9 has not been received, the rules under section 1446 require a partnership to presume that a partner is a foreign person, and pay the section 1446 withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid section 1446 withholding on your share of partnership income. In the cases below, the following person must give Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States. • In the case of a disregarded entity with a U.S. owner, the U.S. owner of the disregarded entity and not the entity; • In the case of a grantor trust with a U.S. grantor or other U.S. owner, generally, the U.S. grantor or other U.S. owner of the grantor trust and not the trust; and • In the case of a U.S. trust (other than a grantor trust), the U.S. trust (other than a grantor trust) and not the beneficiaries of the trust. Foreign person. If you are a foreign person or the U.S. branch of a foreign bank that has elected to be treated as a U.S. person, do not use Form W-9. Instead, use the appropriate Form W-8 or Form 8233 (see Pub. 515, Withholding of Tax on Nonresident Aliens and Foreign Entities). Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a "saving clause." Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes. If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement to Form W-9 that specifies the following five items. 1. The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien. 2. The treaty article addressing the income. 3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions. 4. The type and amount of income that qualifies for the exemption from tax. 5. Sufficient facts to justify the exemption from tax under the terms of the treaty article. Example. Article 20 of the U.S.-China inco me tax treaty allows an exemption from tax for scholarship income rceived by a Chinese student temporarily present in the United Sta es. Under U.S. law, this student will become a resident alien for tax p arposes if his or her stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dad April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (unde- paragraph 2 of the first protocol) and is relying on this exception to cairn an exemption from tax on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the informatier described above to support that exemption. If you are a nonresident alien or a foreign entity, give the requester the appropriate completed Form W-8 or Form 8233. Backup Withholding What is backup withholding? Persons maki:ag certain payments to you must under certain conditions withhold and p -ay to the IRS 24% of such payments. This is called "backup withholding " Payments that may be subject to backup withholding include interes , tax-exempt interest, dividends, broker and barter exchange transacitions, rents, royalties, nonemployee pay, payments made in settler -ant of payment card and third party network transactions, and certain payments from fishing boat operators. Real estate transactions are not sLoject to backup withholding. You will not be subject to backup withholdi ig on payments you receive if you give the requester your correct -IN, make the proper certifications, and report all your taxable interest and dividends on your tax return. Payments you receive will be subject to b=kup withholding if: 1. You do not furnish your TIN to the requester, 2. You do not certify your TIN when require I (see the instructions for Part II for details), 3. The IRS tells the requester that you furni: hed an incorrect TIN, 4. The IRS tells you that you are subject tc )ackup withholding because you did not report all your interest ar d dividends on your tax return (for reportable interest and dividends o ily), or 5. You do not certify to the requester that ypu are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only). Certain payees and payments are exempt f om backup withholding. See Exempt payee code, later, and the separz to instructions for the Requester of Form W-9 for more information. Also see Special rules for partnerships, earl yr. What is FATCA Reporting? The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign financial institution to rel=rt all United States account holders that are specified United Sta es persons. Certain payees are exempt from FATCA reporting. See Exemption from FATCA reporting code, later, and the Instructions for he Requester of Form W-9 for more information. Updating Your Information You must provide updated information to any person to whom you claimed to be an exempt payee if you are no bnger an exempt payee and anticipate receiving reportable payments n the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must f arnish a new Form W-9 if the name or TIN changes for the account; for example, if the grantor of a grantor trust dies. Penalties Failure to furnish TIN. If you fail to furnish year correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect. Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $50( penalty. Form W-9 (Rev. 10-2018) Page 3 Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment. Misuse of TINs. If the requester discloses or uses TINs in violation of federal law, the requester may be subject to civil and criminal penalties. Specific Instructions Line 1 You must enter one of the following on this line; do not leave this line blank. The name should match the name on your tax return. If this Form W-9 is for a joint account (other than an account maintained by a foreign financial institution (FFI)), list first, and then circle, the name of the person or entity whose number you entered in Part I of Form W-9. If you are providing Form W-9 to an FFI to document a joint account, each holder of the account that is a U.S. person must provide a Form W-9. a. Individual. Generally, enter the name shown on your tax return. If you have changed your last name without informing the Social Security Administration (SSA) of the name change, enter your first name, the last name as shown on your social security card, and your new last name. Note: ITIN applicant: Enter your individual name as it was entered on your Form W-7 application, line 1 a. This should also be the same as the name you entered on the Form 1040/1040A/1040EZ you filed with your application. b. Sole proprietor or single -member LLC. Enter your individual name as shown on your 1040/1040A/1040EZ on line 1. You may enter your business, trade, or "doing business as" (DBA) name on line 2. c. Partnership, LLC that is not a single -member LLC, C corporation, or S corporation. Enter the entity's name as shown on the entity's tax return on line 1 and any business, trade, or DBA name on line 2 d. Other entities. Enter your name as shown on required U.S. federal tax documents on line 1. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on line 2. e. Disregarded entity. For U.S. federal tax purposes, an entity that is disregarded as an entity separate from its owner is treated as a "disregarded entity." See Regulations section 301.7701-2(c)(2)(iii). Enter the owner's name on line 1. The name of the entity entered on line 1 should never be a disregarded entity. The name on line 1 should be the name shown on the income tax return on which the income should be reported. For example, if a foreign LLC that is treated as a disregarded entity for U.S. federal tax purposes has a single owner that is a U.S. person, the U.S. owner's name is required to be provided on line 1. If the direct owner of the entity is also a disregarded entity, enter the first owner that is not disregarded for federal tax purposes. Enter the disregarded entity's name on line 2, "Business name/disregarded entity name." If the owner of the disregarded entity is a foreign person, the owner must complete an appropriate Form W-8 instead of a Form W-9. This is the case even if the foreign person has a U.S. TIN. Line 2 If you have a business name, trade name, DBA name, or disregarded entity name, you may enter it on line 2. Line 3 Check the appropriate box on line 3 for the U.S. federal tax classification of the person whose name is entered on line 1. Check only one box on line 3. IF the entity/person on line 1 is a(n)... THEN c heck the box for ... • Corporation Corpo ttion individual • Individual • • company federal Sole Single proprietorship, -member tax (LLC) and purposes. owned disregarded limited or liability by an for U.S. Individual/sole LLC proprietor or single- membr the • U.S. • 2553 or • entity not purposes. LLC LLC LLC owner disregarded treated federal that to that separate be taxed is tax has is another disregarded as filed from a partnership purposes, Form as a its for U.S. LLC 8832 corporation, as owner that federal an is for or but tax the (P= Limited liability nership; corporation) company and enter tax classification. C= C corporation; ap r-opriate Pa- or S= S • Partnership Partne : hip • Trust/estate Trust/eEtate Line 4, Exemptions If you are exempt from backup withholding a.vd/or FATCA reporting, enter in the appropriate space on line 4 any nde(s) that may apply to you Exempt payee code. • Generally, individuals (including sole prop i Mors) are not exempt from backup withholding. • Except as provided below, corporations a .c exempt from backup withholding for certain payments, including iserest and dividends. • Corporations are not exempt from backup vithholding for payments made in settlement of payment card or third F arty network transactions. • Corporations are not exempt from backup vithholding with respect to attorneys' fees or gross proceeds paid to attorneys, and corporations that provide medical or health care services re not exempt with respect to payments reportable on Form 1099-MISC. The following codes identify payees that ari exempt from backup withholding. Enter the appropriate code in the space in line 4. 1 —An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7)1: the account satisfies the requirements of section 401(f)(2) 2 —The United States or any of its agencies Dr instrumentalities 3—A state, the District of Columbia, a U.S. c ommonwealth or possession, or any of their political subdivisi 31S or instrumentalities 4—A foreign government or any of its politinl subdivisions, agencies, or instrumentalities 5—A corporation 6—A dealer in securities or commodities rec uired to register in the United States, the District of Columbia, or a _ .S. commonwealth or possession 7—A futures commission merchant registe ed with the Commodity Futures Trading Commission 8—A real estate investment trust 9 —An entity registered at all times during tis tax year under the Investment Company Act of 1940 10—A common trust fund operated by a bar l under section 584(a) 11—A financial institution 12—A middleman known in the investment cc mmunity as a nominee or custodian 13—A trust exempt from tax under section EE4 or described in section 4947 Form W-9 (Rev. 10-2018) Page 4 The following chart shows types of payments that may be exempt from backup withholding. The chart applies to the exempt payees listed above, 1 through 13. IF the payment is for ... THEN the payment is exempt for... Interest and dividend payments All exempt for 7 payees except Broker transactions Exempt through S exempt are noncovered prior corporations exempt to payees 11 payee 2012. and only securities 1 all must code for through C sales corporations. not because acquired 4 and enter an they of 6 Barter exchange patronage dividends transactions and Exempt payees 1 through 4 Payments reported $5,0001 over and direct $600 required sales over to be Generally, 1 through exempt payees 52 Payments made in settlement payment card or third party transactions of network Exempt payees 1 through 4 1 See Form 1099-MISC, Miscellaneous Income, and its instructions. 2 However, the following payments made to a corporation and reportable on Form 1099-MISC are not exempt from backup withholding: medical and health care payments, attorneys' fees, gross proceeds paid to an attorney reportable under section 6045(f), and payments for services paid by a federal executive agency. Exemption from FATCA reporting code. The following codes identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting this form for accounts maintained outside of the United States by certain foreign financial institutions. Therefore, if you are only submitting this form for an account you hold in the United States, you may leave this field blank. Consult with the person requesting this form if you are uncertain if the financial institution is subject to these requirements. A requester may indicate that a code is not required by providing you with a Form W-9 with "Not Applicable" (or any similar indication) written or printed on the line for a FATCA exemption code. A —An organization exempt from tax under section 501(a) or any individual retirement plan as defined in section 7701(a)(37) B —The United States or any of its agencies or instrumentalities C —A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities D —A corporation the stock of which is regularly traded on one or more established securities markets, as described in Regulations section 1.1472-1(c)(1)(i) E —A corporation that is a member of the same expanded affiliated group as a corporation described in Regulations section 1.1472-1(c)(1)(i) F —A dealer in securities, commodities, or derivative financial instruments (including notional principal contracts, futures, forwards, and options) that is registered as such under the laws of the United States or any state G —A real estate investment trust H —A regulated investment company as defined in section 851 or an entity registered at all times during the tax year under the Investment Company Act of 1940 I —A common trust fund as defined in section 584(a) J —A bank as defined in section 581 K —A broker L —A trust exempt from tax under section 664 or described in section 4947(a)(1) M —A tax exempt trust under a section 40 3(b) plan or section 457(g) plan Note: You may wish to consult with the finar cial institution requesting this form to determine whether the FATCA c )de and/or exempt payee code should be completed. Line 5 Enter your address (number, street, and apa-tment or suite number). This is where the requester of this Form W-5 will mail your information returns. If this address differs from the one tie requester already has on file, write NEW at the top. If a new address is provided, there is still a chance the old address will be used until the payor changes your address in their records. Line 6 Enter your city, state, and ZIP code. Part I. Taxpayer Identificatic n Number (TIN) Enter your TIN in the appropriate box. If you are a resident alien and you do not have and are not eligible to get a ISSN, your TIN is your IRS individual taxpayer identification number (ITI J). Enter it in the social security number box. If you do not have an '—IN, see How to get a TIN below. If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. If you are a single -member LLC that is dis 'egarded as an entity separate from its owner, enter the owner's SSN (or EIN, if the owner has one). Do not enter the disregarded entity's EN. If the LLC is classified as a corporation or partnership, enter the entitys EIN. Note: See What Name and Number To Give the Requester, later, for further clarification of name and TIN combinations. How to get a TIN. If you do not have a TIN apply for one immediately. To apply for an SSN, get Form SS -5, Applicz Lion for a Social Security Card, from your local SSA office or get this firm online at www.SSA.gov. You may also get this form bi calling 1-800-772-1213. Use Form W-7, Application for IRS Individua Taxpayer Identification Number, to apply for an ITIN, or Form SS -4 application for Employer Identification Number, to apply for an EIN. V nu can apply for an EIN online by accessing the IRS website at www irs.gov/Businesses and clicking on Employer Identification Number ; =lN) under Starting a Business. Go to www.irs.gov/Forms to viev4, download, or print Form W-7 and/or Form SS -4. Or, you can go to t./ vw.irs.gov/OrderForms to place an order and have Form W-7 and/or S 3-4 mailed to you within 10 business days. If you are asked to complete Form W-9 b: do not have a TIN, apply for a TIN and write "Applied For" in the space, for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with -espect to readily tradable instruments, generally you will have 60 days :o get a TIN and give it to the requester before you are subject to backup withholding on payments. The 60 -day rule does not apply tc other types of payments. You will be subject to backup withholding or all such payments until you provide your TIN to the requester. Note: Entering "Applied For" means that ycL have already applied for a TIN or that you intend to apply for one soon. Caution: A disregarded U.S. entity that has a foreign owner must use the appropriate Form W-8. Part II. Certification To establish to the withholding agent that ycJ are a U.S. person, or resident alien, sign Form W-9. You may be requested to sign by the withholding agent even if item 1, 4, or 5 below indicates otherwise. For a joint account, only the person whose_ TIN is shown in Part should sign (when required). In the case of a disregarded entity, the person identified on line 1 must sign. Exemp payees, see Exempt payee code, earlier. Signature requirements. Complete the certfication as indicated in items 1 through 5 below. Form W-9 (Rev. 10-2018) Page 5 1. Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active during 1983. You must give your correct TIN, but you do not have to sign the certification. 2. Interest, dividend, broker, and barter exchange accounts opened after 1983 and broker accounts considered inactive during 1983. You must sign the certification or backup withholding will apply. If you are subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 in the certification before signing the form. 3. Real estate transactions. You must sign the certification. You may cross out item 2 of the certification. 4. Other payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. "Other payments" include payments made in the course of the requester's trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (including payments to corporations), payments to a nonemployee for services, payments made in settlement of payment card and third party network transactions, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attorneys (including payments to corporations). 5. Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), ABLE accounts (under section 529A), IRA, Coverdell ESA, Archer MSA or HSA contributions or distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification. What Name and Number To Give the Requester For this type of account: Give name and SSN of: 1. Individual 2. Two or more individuals (joint account) other than an account maintained by an FFI 3. Two or more U.S. persons (joint account maintained by an FFI) 4. Custodial account of a minor (Uniform Gift to Minors Act) 5. a. The usual revocable savings trust (grantor is also trustee) b. So-called trust account that is not a legal or valid trust under state law 6. Sole proprietorship or disregarded entity owned by an individual 7. Grantor trust filing under Optional Form 1099 Filing Method 1 (see Regulations section 1.671-4(b)(2)(i) (A)) The individual The actual owner of the account or, if combined funds, the first individual on the account' Each holder of the account The minor2 The grantor -trustee' The actual owner' The owner3 The grantor* For this type of account: Give name and EIN of: 8. Disregarded entity not owned by an individual 9. A valid trust, estate, or pension trust 10. Corporation or LLC electing corporate status on Form 8832 or Form 2553 11. Association, club, religious, charitable, educational, or other tax- exempt organization 12. Partnership or multi -member LLC 13. A broker or registered nominee The owner Legal entity4 The corporation The organization The partnership The broker or nominee For this type of account: C✓e name and EIN of: 14. Account with the Department of Agriculture in the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program payments 15. Grantor trust filing under the Form 1041 Filing Method or the Optional Form 1099 Filing Method 2 (see Regulations section 1.671-4(b)(2)(i)(B)) The pudic entity The ' List first and circle the name of the person whose number you furnish. If only one person on a joint account has an :SSN, that person's number must be furnished. 2 Circle the minor's name and furnish the mi-cr's SSN. 3 You must show your individual name and "u may also enter your business or DBA name on the "Business nal e/disregarded entity" name line. You may use either your SSN or N (if you have one), but the IRS encourages you to use your SSN. 4 List first and circle the name of the trust, es -ate, or pension trust. (Do not furnish the TIN of the personal represents Live or trustee unless the legal entity itself is not designated in the acct unt title.) Also see Special rules for partnerships, earlier. *Note: The grantor also must provide a Form W-9 to trustee of trust. Note: If no name is circled when more than one name is listed, the number will be considered to be that of the rest name listed. Secure Your Tax Records From Identity Theft Identity theft occurs when someone uses yc Lr personal information such as your name, SSN, or other identifying information, without your permission, to commit fraud or other crimes ekn identity thief may use your SSN to get a job or may file a tax return .asing your SSN to receive a refund. To reduce your risk: • Protect your SSN, • Ensure your employer is protecting your S El, and • Be careful when choosing a tax preparer. If your tax records are affected by identity tieft and you receive a notice from the IRS, respond right away to te name and phone number printed on the IRS notice or letter. If your tax records are not currently affects i by identity theft but you think you are at risk due to a lost or stolen pL_ -se or wallet, questionable credit card activity or credit report, contact ti- e IRS Identity Theft Hotline at 1-800-908-4490 or submit Form 14039. For more information, see Pub. 5027, Ider. ty Theft Information for Taxpayers. Victims of identity theft who are experienci ig economic harm or a systemic problem, or are seeking help in resclving tax problems that have not been resolved through normal chan iels, may be eligible for Taxpayer Advocate Service (TAS) assistance You can reach TAS by calling the TAS toll -free case intake line at 1-177-777-4778 or TTY/TDD 1-800-829-4059. Protect yourself from suspicious emails op phishing schemes. Phishing is the creation and use of email and-websites designed to mimic legitimate business emails and websi -5. The most common act is sending an email to a user falsely claiminc :o be an established legitimate enterprise in an attempt to scam tt e user into surrendering private information that will be used for iden: :y theft. Form W-9 (Rev. 10-2018) Page 6 The IRS does not initiate contacts with taxpayers via emails. Also, the IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers, passwords, or similar secret access information for their credit card, bank, or other financial accounts. If you receive an unsolicited email claiming to be from the IRS, forward this message tophishing@irs.gov. You may also report misuse of the IRS name, logo, or other IRS property to the Treasury Inspector General for Tax Administration (TIGTA) at 1-800-366-4484. You can forward suspicious emails to the Federal Trade Commission at spam@uce.gov or report them at www.ftc.gov/complaint. You can contact the FTC at www.ftc.gov/idtheft or 877-1OTHEFT (877-438-4338). If you have been the victim of identity theft, see www.IdentityTheft.gov and Pub. 5027. Visit www.irs.gov/IdentityTheft to learn more about identity theft and how to reduce your risk. Privacy Act Notice Section 6109 of the Internal Revenue Code -Bquires you to provide your correct TIN to persons (including federal ag ncies) who are required to file information returns with the IRS to reporinterest, dividends, or certain other income paid to you; mortgage i iterest you paid; the acquisition or abandonment of secured pro erty; the cancellation of debt; or contributions you made to an IRA, . s -cher MSA, or HSA. The person collecting this form uses the informaton on the form to file information returns with the IRS, reporting t > 3 above information. Routine uses of this information include givi---g it to the Department of Justice for civil and criminal litigation and tc :ities, states, the District of Columbia, and U.S. commonwealths and pc sessions for use in administering their laws. The information als: may be disclosed to other countries under a treaty, to federal and stab- agencies to enforce civil and criminal laws, or to federal law enforcer-ent and intelligence agencies to combat terrorism. You must prcc ide your TIN whether or not you are required to file a tax return. Und= section 3406, payers must generally withhold a percentage of taxzle interest, dividend, and certain other payments to a payee who doe : not give a TIN to the payer. Certain penalties may also apply for providir g false or fraudulent information. Jessica Reid From: Sent: To: Subject: Attachments: Edwards, Rachel <racheledwards@chevron.com> Thursday, May 18, 2023 3:05 PM CTB-Oil and Gas Leasing RE: After -Payout status payment Jones, Walter 01-26 CD - Weld County - Signed Settlement Letter.pdf Caution: This email originated from outside of Weld County Government. Do not click links or open attachments unless you recognize the sender and know the content is safe. Afternoon, The check sent was for this well for the APO Settlement- • Jones Walter 01-26 (T6N-R66W Section 26: W2NE4) Settlement Summary « ell Name . Owner Settlement Beginning Date b Settlement End Date Revenue Net Net Costs Settlement Amount (Revenue minus Cost) Jones,Walter 1-26 CD Weld County Co 6/16/1993 11/30/2013 1,741.38 N/A , 1,741.38 Rachel Edwards Land Representative racheledwards@chevron.com (303) 228-4345 Chevron Rockies Business Unit Noble Energy, Inc. 2001 16th Street, Suite 900 Denver, CO 80202 From: CTB-Oil and Gas Leasing <CTB-OilandGasLeasing@co.weld.co.us> Sent: Thursday, May 18, 2023 2:44 PM To: Edwards, Rachel <racheledwards@chevron.com> Cc: CTB-Oil and Gas Leasing <CTB-OilandGasLeasing@co.weld.co.us> Subject: [* * EXTERNAL**] After -Payout status payment Be aware this external email contains an attachment and/or link. Ensure the email and contents are expected. If there are concerns, please submit suspicious messages to the Cyber Intelligence Center using the Report Phishing button. Hi Rachel, Can you please provide me the Reception number associated with the lease(s) this form is referring to? Also, which wells specifically? Jess Reid 1 cpsoie-io H Deputy Clerk to the Board Weld County 1150 O Street Greeley, CO 80631 tel 970-400-4212 Confidentiality Notice This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited 2 Hello