VTB Form G 04/2018 See Vt. LBR 3018-3 & 3020-1 UNITED STATES BANKRUPTCY COURT DISTRICT OF VERMONT In re: , Chapter 11 Debtor(s). Case # SUMMARY BALLOT REPORT AND CERTIFICATION [The Plan Proponent], by and through its attorney [name of attorney] and hereby summarizes, reports, and certifies to the Court the results of the balloting on the [Plan Proponent]222s Chapter 11 Plan of Reorganization (hereinafter, the 223Plan224), dated , and in making such report states as follows: TIMELY AND UNTIMELY FILED BALLOTS 1. Of the [number] ballots issued, [number] ballots were filed. 2. Of the filed ballots, [number] were timely filed and [number] were untimely filed. 3. Of the timely filed ballots, [number] accepted the Plan and [number] rejected the Plan. SUMMARY OF BALLOTING BY CLASS 1. Class [#] [name or identity of class]: This class is impaired, has voted upon the Plan, and [ACCEPTS/REJECTS] the Plan. Class [#] Ballots Claims in terms of $ Total in c lass [ # of ballots distributed ] [ $ amount of allowed claims ] # f iled [ # of ballots ] [ (% of tota l)] [ $ amount ] [ (% of total) ] f or Plan [ # of ballots ] [ (% of total) ] [ $ amount ] [ (% of total) ] a gainst Plan [ # of ballots ] [ (% of total) ] [ $ amount ] [ (% of total) ] 2. Class [#] [name or identity of class]: This class is impaired, has voted upon the Plan, and [ACCEPTS/REJECTS] the Plan. Class [#] Ballots Claims in terms of $ Total in c lass [ # of ballots distributed ] [ $ amount of allowed claims ] # f iled [ # of ballots ] [ (% of total) ] [ $ amount ] [ (% of total) ] f or Plan [ # of ballots ] [ (% of total) ] [ $ amount ] [ (% of total) ] a gainst Plan [ # of ballots ] [ (% of total) ] [ $ amount ] [ (% of total) ] American LegalNet, Inc. www.FormsWorkFlow.com VTB Form G 04/2018 See Vt. LBR 3018-3 & 3020-1 3. Class [#] [name or identity of Class]: This class is impaired, has balloted upon the Plan, and [ACCEPTS/REJECTS] the Plan. Class [#] Ballots Claims in terms of $ Total in c lass [ # of ballots distributed ] [ $ amount of allowed claims ] # f iled [ # of ballots ] [ (% of total) ] [ $ amount ] [ (% of total) ] f or Plan [ # of ballots ] [ (% of total) ] [ $ amount ] [ (% of total) ] a gainst Plan [ # of ballots ] [ (% of total) ] [ $ amount ] [ (% of total) ] [Provide as many additional summary paragraphs as necessary.] CERTIFICATION I certify that the [Plan Proponent] retains the voted ballots and will, upon request of the Court, the debtor-in-possession, the case trustee (if any), and/or the U.S. Trustee, produce copies of all such ballots. I further certify that the above summary report is an accurate summary of all classes, all allowed claims, and all ballots voted, and that this summary complies with Vt. LBR 3018-3. Dated: Authorized Agent of Plan Proponent By: Printed name of signatory Address E-mail address Telephone number American LegalNet, Inc. www.FormsWorkFlow.com