Division Order Model Blank Form 2015 printable pdf download

Division Order Model Blank Form 2015

NADOA Model Form Division Order (Adopted 9/95 – Amended 2/15)

OIL & GAS DIVISION ORDER

Property Number:

Date Prepared:

Property Name:

Effective Date:

Operator:

County/State:

Property Description:

Production:

Oil _____ Gas _____ Other _____

Owner Name:

Owner Number:

Address:

Type of Interest:

Interest:

The undersigned certifies the ownership of their decimal 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 receipt of such notice.

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 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 $

, or pay

, whichever

occurs first, or as required by applicable state statutes.

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:

Witness:

Owner(s) Signature

Owner(s) Tax ID/SS No.:

Owner(s) Daytime Telephone No:

Owner(s) Email Address.:

FEDERAL LAW REQUIRES YOU TO FURNISH YOUR SOCIAL SECURITY OR TAXPAYER IDENTIFICATION NUMBER. FAILURE

TO COMPLY WILL RESULT IN TAX WITHHOLDING IN ACCORDANCE WITH FEDERAL LAW, WHICH WILL NOT BE

REFUNDABLE BY PAYOR.

Division Order Model Blank Form 2015