B-3018-1 (rev 10/1/12) UNITED STATES BANKRUPTCY COURT Southern District of Indiana In re: [Name of Debtor(s)], Debtor(s). ) ) ) ) Case No. (xx-xxxxx) CERTIFICATION OF BALLOTING REPORT The plan proponent, (name of plan proponent), hereby certifies that the tabulations recorded on the attached balloting report are true and correct and that all classes of creditors are accurately represented as to acceptances, rejections, and total amounts for each class of claims or interests. /s/ Name of Plan Proponent Name of Plan Proponent (required signature block) CERTIFICATE OF SERVICE (See "Certificate of Service - Generic" on the Court's website under "Forms/Local/Motions & Related Notices-Certificates of Service-Orders/Certificates of Service/Generic.") (Note: Attach B-3018-1 Balloting Report form.) American LegalNet, Inc. www.FormsWorkFlow.com