Fill and Sign the Nadoa Model Form Division Order Adopted 995

NADOA Model Form Division Order (Adopted 9/95) DIVISION ORDER To: (PAYOR NAME) Date: (DATE D.O. ISSUED) (PAYOR ADDRESS) (PAYOR PHONE/FAX#) Property Number: (PAYOR’S PROPERTY NUMBER) Effective Date: (EFFECTIVE DATE) Property Name: (PROPERTY NAME) Operator: (PROPERTY OPERATOR) County and State: (COUNTY / STATE) Property Description: (PROPERTY LEGAL DESCRIPTION) (this space can be enlarged or an exhibit used) Production: Oil: Gas: Other: Owner Name and Address: (PAYEE’S NAME AND ADDRESS) OWNER NUMBER: (INTEREST OWNER NUMBER) Type of Interest: (OWNERSHIP INTEREST TYPE) Decimal Interest: (OWNERSHIP DECIMAL AND/OR FRACTION) The undersigned certifies the ownership of their decimal interest in production or proceeds as described above payable by (company name/payor). (Company name/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. Company name/payor) 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 indemnity and reimburse (company name) any amount attributable to an interest to which the undersigned is not entitled. (Company name/payor) may accrue proceeds until the total amount equals $ (amount), or pay (time period), whichever occ urs 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 (company name/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(s) Tax I.D. Number(s): _____________________________ ______________________________ Owner Daytime Telephone #: _____________________________ ______________________________ Owner FAX Telephone #: _____________________________ ______________________________ 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 (Company name/payor). Use and Definition of Fields for NADOA Model Form Division Order The Model Form Division Order contains several blanks to be completed prior to mailing. Following are definitions of the information to be inserted in each blank, that, when completed properly, will insure both the payee (interest owner) and payor that the proceeds from the oil or gas production are being paid correctly: (PAYOR) – the name and address of the person who is paying. (DATE D.O. ISSUED) – the actual date the Division Order is prepared. This date is helpful t o both the payee and the payor so that a specific Division Order can be identified and reviewed if questions arise. (EFFECTIVE DATE) – the day when sales first occurred or when the payee’s interest is effect ive. This date identifies the earliest date which will be included in payments subject to this Division Order. For new wells, it is preferable to include an actual date, rather than using “date of first sales” (DOFS) or “date of first production” (DOFP). (PAYOR’S PROPERTY NUMBER) – the property, lease or division order number used by the payor that will actually appear on the check detail when payment is made to the payee. T his number can then be readily identified by the payee and referred to when making an inquiry. If the payor requires other numbers within the ir computer, accounting, or filing systems, these numbers should be listed elsewhere on the form for internal reference only. (PROPERTY NAME) – the property, lease or well name in which the payee owns an interest a nd from which proceeds will be received. The property name should be the same as, or as close as possible to, that used by the operator for reporting production volumes to the State. (PROPERTY OPERATOR) – the operator of the property, lease or well. Identifying the operator is particularly important when the payor is not the operator. Knowing the operator’s name can help the payee to obtain information, such as production volumes which are available at the state agencies. (COUNTY/STATE) – the county (or parish) and state where the property, lease, or well is located. (PROPERTY DESCRIPTION) – the description of the property from which production proceeds are being paid pursuant to this Division Order. The property description should be meaningful to the payee so t hat the payee can determine that the interest is correct. (PRODUCTION) – the type of production (oil, gas, sulfur, helium, etc.) for which the payor is making di stribution under this Division Order. Since different payors may distribute proceeds from different types of producti on or ownership can be different for various products, it is important that the type of production be i ncluded on the Division Order. Products other than oil or gas should be listed. (PAYEE’S NAME & ADDRESS) – the payee’s name and address. The owner should verify the spelling of their name and the correctness of their address. The address listed should be the address to which the check payment (or payment detail if the payee has elected to have their payment electronically deposited to t heir bank) will be mailed.