Fill and Sign the Nadoa Journal Nadoa Model Form Division Order

DIVISION ORDER(Standard Form) Date D.O. Issued: To: (Payor Name/Address) Effective Date: Property Number: Property Name: Operator: County and State: Property Description: Production: Oil Gas Other: Owner Number: Type of Interest: Owner Name: (Payee’s Name/Address) Decimal Interest: The undersigned certifies the ownership of the decimal interest in production or proceeds as described above payable by 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 rec eipt of such notice. Payor is authorized to withhold payment pending resolution of title dispute or adverse claim asserted regarding interest in production claimed herein by the undersigned. The undersigned agrees to indemnify and reimburse Payor any amount attributable to an interest t he undersigned does not own. Payor may accrue proceeds until the total amount equals $____, or pay (Time Period) , whichever occurs first, or as required by applicable state statute. This Division Order does not amend any oil and gas lease or operating agreement between the undersigned and the lessee, or operator, or any other contracts for the purchase of oi l 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: (None or See Exhibit "A") Owner(s) Signature(s): (Owner Name)(Owner Name) Owner Tax I.D. Number Owner Tax I.D. Number Owner Telephone #Owner Telephone # Owner Work Telephone # Owner Work Telephone # Owner FAX Telephone #: Owner FAX Telephone #: Federal Law requires you to furnish your Social Security or Taxpayer Identification Number. Failure to comply will result in ____% tax withholding and will not be refundable by Payor.